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YOUNG 

How Typhoid 

Fever is Spread 

AND 

Notes on Dysentery and Cholera 

1906 



Reprinted from its fourteenth report 

hy the State Board of Health of Maine . 



CONTENTS. 



Typhoid Fever. page 

Cause of Typhoid Fever , i 

Source of the Infection i 

Typhoid Fever a General Infection i 

How is the Infection Excreted? 3 

Life of Typhoid Infection Outside the Body 7 

How May Typhoid Fever be Contracted? 8 

Contact Infection 8 

Finger Infection 13 

Transmission by Clothing 15 

Typhoid Houses 17 

Typhoid Distributed by Flies 19 

Danger from the Sputum 21 

From Wells and Springs , 22 

Life of the Typhoid Bacillus in the Ground 27 

From Public Water Supplies 31 

Vitality of the Typhoid Bacillus in Water 35 

Self-Purification of Rivers 38 

Typhoid from Milk Supplies 40 

Typhoid from Oysters 44 

Typhoid Fever from Other Food Products 49 

Air-Borne Infection 50 

Other Sources of Infection.. 51 

Primary and Secondary Cases 51 

Atypical Cases of Typhoid Fever 53 

Notes on Dysentery and Cholera. 

Notes on Dysentery.. 59 

Notes on Cholera 64 



1 



HOW TYPHOID FEVER IS SPREAD. 
By A. G. Young, M. D., Secretary of the Board. 

The demonstration that typhoid fever is a water-borne disease 
was a distinct advance in our knowledge of the causation of our 
communicable diseases. That water is often a distributor of 
typhoid fever is so positively established that there is no danger 
that it can ever be successfully assailed. Nevertheless, the col- 
lector of these notes believes that the fact that typhoid fever is 
often spread by water has come so to overshadow in the pub- 
lic mind other means by which it is communicated that the effi- 
ciency of our effort to limit the prevalence of this serious dis- 
ease is much lessened. Believing this he wishes to present some 
of the facts and observations which indicate that the public gen- 
erally, and some of the members of the medical profession even, 
in their teachings and in their warnings to the families under 
their care, should take a broader view of the means by which 
typhoid infection is distributed and of the scope of the required 
precautionary measures. 

The Cause of Typhoid Fever. — It is understood nowadays by 
the intelligent public generally, that typhoid fever is the result 
of the action of a specific kind of infection — the bacillus of 
typhoid fever. This infectious disease never originates de novo, 
nor as the result of a cold, ordinary disturbances of the digestive 
system, nor even from the uses of polluted, unclean, or decaying 
food or drink unless they contain, or are infected by the typhoid 
bacillus. 

Source of the Infection. — This specific infection of typhoid 
fever always comes directly or indirectly from previous cases of 
typhoid fever, usually near, but occasionally somewhat remote as 
regards time. 

Typhoid Fever a General Infection. — Probably the generally- 
accepted opinion is correct that the typhoid infection is, at first, 
a local process confined to the intestinal tract, but recent research 



2 



leaves this point just a little doubtful. Upon the question o. 
the general diffusion of the infection through the system, or of 
the frequency in which a general infection results, the teachings 
of even the recent editions of the text-books and of the latest 
observations, are hardly in accord. For instance. Professor 
Klemperer^ says : 

"In the circulating blood of the enteric fever patient the 
demonstration of the bacilli has also been possible — for example, 
in the blood of the veins, after blood has been removed by a 
syringe — but this appears to be exceptional. As a rule, the 
blood of the patient during life is sterile, the important road of 
transport of the bacilli appears to be by the lymph system." 

On the other hand later investigators have found that the 
typhoid bacillus pervades the general circulatory system in a 
pretty large percentage of cases examined, and that this general 
infection occurs early in the course of the disease in a consider- 
able number of cases at least. 

"Dr. Ruediger^ found that, in thirty cases of typhoid fever 
investigated by him, typhoid bacilli or paratyphoid bacilli were 
present in the blood in the earlier days of the disease. The dif- 
ferential diagnosis between the typhoid and the paratyphoid 
bacillus cultivated from the blood is easy, and the demonstration 
of the bacilli in the blood is comparatively simple." 

Dr. Von Drigalski, a brigade surgeon at Kassel, Germany, 
and one of the men who is taking an active part in the advanced 
work in that country in the control of typhoid fever says :^ 

"By the way of the mouth only the bacillus of typhoid fever 
reaches the organism of its victim and implants itself usually, if 
not invariably, in the intestinal tract from which it pervades the 
whole system so that generally the bacilli may be found almost 
everywhere, particularly in the liver, the bile, in the lungs even 
when there is no apparent pulmonary disease ; almost constantly 
in the mucus membrane of the stomach, in the esophagus, fre- 
quently on the surface and in the depths of the tonsils, and 
occasionally from the tongue successful cultures of the typhoid 
bacilli have been made. In the intestinal tract, they are more 
plentiful where the specific pathological changes have not 
occurred, the most plentiful in the duodenum, while they may be 
present only sparingly or not at all in the parts of the colon 
where the swollen and ulcerated glands are present. What a 
mass of typhoid bacilli are produced in the diseased body is 

1. Modern Clinical Medicine, Edition of 1905. 

2. Tr. Chicago Pathol. Soc.—Centr. fur Bak., XXXIIL, 291. 

3. Deutsche Viert. f. off. Ges., XXXVIII., 22, 1906. 



3 

almost incredible. There is hardly a secretion or excretion of 
the patient which does not contain the germ. In the perspira- 
tion, however, it has not as yet been demonstrated with 
certainty." 

J. L. Hirsh,^ Professor of Pathology in the University of 
Maryland, with the aid of two assistants, examined the blood in 
100 cases of typhoid fever and found bacilli present in the cir- 
culating blood in 78 and absent in 22 cases. The largest num- 
ber of positive findings were in the second week of the disease, 
but in 16 cases examined during the first week, 12 were positive. 
His conclusions are that the bacillus typhosus is present in the 
circulating blood in every case of typhoid fever some time dur- 
ing its course ; that the bacilli invade the blood very early in the 
disease ; and that they usually disappear from the blood by the 
end of the third week. 

Hirsh opens his paper by saying that "the views regarding the 
nature of typhoid fever have undergone considerable changes in 
recent years. While this was formerly considered as an intesti- 
nal disease, or as a disease with especial localization in the intes- 
tinal tract, the modern conception regards it as a true septicemia. 
Instead of local lesions in the intestines with subsequent blood 
infection, the organisms of the disease are first conveyed to the 
general circulation and the intestinal lesions, when present, are 
to be regarded as the secondary changes." 

Auerbach and Unger^ in their investigations as to the presence 
of the typhoid bacillus in the blood of typhoid fever patients, 
obtained it from the blood in seven out of ten cases in which a 
definite clinical diagnosis had been made. 

In twenty-eight cases of typhoid fever, all severe cases, Cour- 
mont and Lesieur^ succeeded in showing the presence of the 
typhoid bacillus in the blood by inoculating from 2 to 3 c. m. of 
blood into 250 c. m. of bouillion. They succeeded thus in mak- 
ing cultures of typhoid bacilli from the first day to the third 
week. 

How is the Infection Bxcretedf — If typhoid fever is so fre- 
quently a general infection, it suggests that the range of possible 
danger extends to a larger number of the excretions from the 

1. Jr. of Am. Medical Assoc., XLVI., 1922. 1906. 

2. Deutsche Viert. f. off. Ges., XXXIII., 142 1902. 

3. Deutsche Viert. f. off. Ges., Sup., XXXVI., 148. 1905. 



4 



typhoid patient than it has been usual to take into account in 
our regulations designed to prevent the spread of the infection. 
While we are still to consider the discharges from the bowels as 
the main source of infection, other excretions require thorough 
disinfection or destruction. 

In the report of Drs. Reed, Vaughan, and Shakespeare, con- 
stituting the commission appointed to investigate the prevalence 
of typhoid fever in the U. S. military camps in 1898, the follow- 
ing opinions are expressed : 

The stools of individuals sick with typhoid fever constitute 
the most important source for the spread of this disease, and it 
may be stated in a general way that typhoid fever is due to the 
transference of some part of the feces of an infected individual 
to the alimentary canal of one susceptible to this infection. 
This transference in exceptional cases may be quite direct, as 
when a careless nurse soils her hands with the dejections from 
her typhoid fever patient and eats her food without disinfecting 
her soiled fingers. Generally, however, the transference is more 
indirect and the germs in the infected stools may multiply 
through many generations and be transported by water or other- 
wise through considerable distances. Moreover, as has been 
indicated already, the bacilli may pass through an intermediate 
host, which may be man or one of the lower animals. An 
immune individual may visit a distant city, the water supply of 
which is infected with the typhoid bacillus, and he may carry 
this infection to his village home, where it may be deposited in 
his normal stool, may find its way into the local water supply, 
and cause an epidemic of the disease. 

" It should be borne in mind that typhoid stools are infectious 
often before the individual shows any evidence of the disease. 
In other words, the stool of a man in the incubation period of 
typhoid fever may be laden with the bacilli of this disease. In: 
this way every latrine in an encampment may be infected with 
the specific micro-organism of typhoid fever before the disease 
has developed sufiiciently in the individual to be recognized clin- 
ically. On the other hand, the stools may continue to be infec- 
tious long after convalescence has set in. So great is the dan- 
ger of the spread of this disease from infected stools that in all 
cases where fecal matter can not be removed by water carriage, 
or otherwise, from immediate proximity with human habitation, 
all stools, those of both sick and well, should be thoroughly 
disinfected." 

The most significant result of recent investigations is that the 
urine of typhoid patients frequently contains the typhoid bacillus 
in enormous numbers, and that such persons, disseminators of 
infection, may constitute serious sources of danger far into the 



5 



period of convalescence and even sometimes until long after 
the recovery of the patient appears to be complete. 

A further significant fact is that the expectoration of the 
typhoid fever patient may be dangerously loaded down with the 
bacillus : 

" In 1890, Neumann demonstrated typhoid-bacilli in the urine 
of 1 1 out of 48 cases examined. His results were received with 
some skepticism, however, and received no confirmation until 
Petruschky, in 1898, published the results of cultures from the 
urine in 50 cases, with isolation of B. typhosus from 3. Later, 
Richardson obtained the bacilli from 23 out of 104 cases exam- 
ined — 22.1 per cent.; and Horton-Smith obtained them from 
II of 39 cases, 28 per cent. — the urine containing at times as 
many as 50,000,000 organisms in each cubic centimeter. Dur- 
ing the past year, 1900-1901, from the urine of 55 typhoid 
fever patients in the Johns Hopkins Hospital the typhoid bacilli 
were isolated in 19 cases." ^ 

Richardson^ found that typhoid bacilli may remain in the 
urine for weeks and months, thus exposing to danger persons 
in the neighborhood of the convalescents. In the expectoration 
of typhoid fever patients with lung complications the typhoid 
bacillus is present in the sputum, together with the pneumoccus 
and the influenza bacillus. The urine and the expectoration of 
typhoid patients must therefore be carefully disinfected. 

Stefanalli and Cumbo^ studied twenty-one cases of typhoid 
fever and for each case a bacteriological examination of the 
urine and blood was made, and the Widal test was employed. 
From this study they conclude that the typhoid bacillus may be 
found in the urine at any time in the course of the disease 
whether it contains album.en or not. They thus found the bacil- 
lus in 30 per cent, of the cases. Its presence may be transitory 
or last through the whole course of the disease. 

According to Schuzer,* in 599 cases of typhoid fever the 
typhoid bacillus was found in the urine in 177 cases, or in 29.5 
per cent, of them. 

Burdach^ found the bacillus in 10 of 25 typhoid fever patients 
and he refers to the investigations of other observers upon 360 

1. Typhoid and Typhus Fever, Nothnagel's Ency. of Pract. Med. p. 
34, 1902. 

2. British Medical Journal, Feb. 5, 1903. 

3. Rivista Crit. di Clin. Medica. 

4. D. Viert. f. off, Ges., XXXIV., 153. 1903. 

5. Zeit, f. Hygiene, XLL, 305, 1902. 



6 



patients, in 129 of whom or in 33%, the bacillus was present in 
the urine. 

The urine, says Drigalski,^ may be entirely clear and normal 
in appearance and yet contain an abundant quantity of the 
typhoid bacilli, and the dejections which appear to be entirely 
normal may contain the infection until long into the period of 
convalescence. At the time particularly when the clinical con- 
valescence is progressing and appetite and digestion are again 
restored, the excretions of the typhoid bacilli are particularly 
frequent and plentiful, so that the bacterial flora of the stools 
sometimes consist of a pure culture of the typhoid bacillus. 

Naturally the frequency of this phenomenon varies, and for- 
tunately not every convalescent is such a source of new infec- 
tions. I have found the bacillus present in the excretions of 
the patient in 15% of the cases in the first 5 days; in 11% still 
present after 8 or 10 weeks ; in 4% longer than 3 months. For 
the reason that the convalescent is frequently excreting the 
infection after he has resumed |iis ordinary life and is in close 
communication with others, he is particularly dangerous to his 
associates. 

Houston- reported a case of cystitis of three year's standing 
due to the infection of the bladder with the typhoid bacillus. 
An interesting point in this case is that the patient never had 
typhoid fever, but had nursed cases of that disease. 

In Jehle's^ examination of the expectoration of typhoid 
patients he found the bacillus present in nine out of fifteen cases. 
In all these cases typhoid was complicated by bronchitis or 
broncho-pneumonia. The t3^phoid bacilli existed in pure cul- 
ture in 2 cases, in 4 cases they existed very numerously, in 2 
cases they were associated with the influenza bacilH, and in I 
case with diplococci and streptococci. 

The results of the examination of the bronchial mucus were 
as follows : In 5 cases in which there existed hasmorrhag^c 
infiltration of the lungs the typhoid bacilli were found 4 times. 
In 6 cases with simply a congested condition of the lung tissue 
the presence of typhoid bacilli were proved 4 times. 

Numerous observations have shown that the typhoid bacillus 
retains its vitality for a long while when enclosed in the inflam- 
atory exudates which are the result of its action in various parts 

1. Deutsche Viert. f. off. Ges., XXXVIII., 23, 1906. 

2. British Med. Jr., 1899, !•» 7^- 

3. Wiener Klin. Woch.— Public Health, XIV., 630, 1902. 



7 



of the body, for instance, in purulent collections in periostitis, 
abscesses of the muscles and elsewhere, in cystitis, but these 
exudates are infrequent sources of infection. The main and 
the most frequent sources of supply of infection are the dis- 
charges from the bowels and the urine, and next to those the 
sputum, particularly where there are indications of pulmonary 
involvment. 

Life of Typhoid Infection Outside the Body. — The life his- 
tory of the bacillus of typhoid fever after it leaves the human 
body, its power of resisting adverse influences, and of retaining 
its vitality, have been the subjects of an immense amount of 
patient and careful investigation. Briefly stating some of the 
results, it may be said that direct and unobstructed sunlight 
rapidly destroys the life of the bacillus, but its power of resist- 
ance is greater than that of many other pathogenic micro-organ- 
isms, or, partly protected from its action, it perishes more 
slowly. Drying is not so rapidly destructive of its vitality as 
was formerly assui-cd. Dried in the dark it remains actively 
viable many days. It easily survives any degree of cold found in 
nature and remains uninjured by repeated freezings and thaw- 
ings. By heat Sternberg found that the typhoid bacillus is 
destroyed at the temperature of 140° F., and Bessenge confirms 
this statement when this temperature is continued five minutes. 
Under the conditions of the outer world, the various other bac- 
teria found under natural conditions in water, in the soil, etc., 
inhibit the growth of the typhoid bacillus or cause it to dis- 
appear. Even when exposed to the competition of the bacterial 
flora in natural waters, its survival of a few days to a month or 
more confirms the observation of epidemological study as to the 
danger from water infected with this specific bacterium. In the 
polluted soil around houses or out-buildings, the infectivity of 
the typhoid germ may continue some months at least. It finds 
a congenial culture fluid in milk, and, in the laboratory, the 
bacteriologist secures a rapid growth of it upon the cut surface 
of a boiled potato. Upon clothing and in rooms the infection 
may persist for a long time under favorable conditions, such as 
frequently pertain to fabrics and dwellings. 

All those facts call for careful, intelligent measures for safe- 
guarding human environments from being seeded down with 
the infection of typhoid fever. 



8 



How May Typhoid Fever he Contracted? — In the investiga- 
tion of the sources of infection in outbreaks of typhoid fever, 
and of the means through which the infection reached its 
victims, the search, if intelHgently made, cannot be confined to 
a few long-accepted ways in which the infection may have been 
received. The investigation must be comprehensive enough to 
include all of the methods of transmission which recent research 
has shown are probable or even only possible. 

In the following notes which indicate some of the methods 
by which typhoid fever is spread, there is no attempt to enu- 
merate them in the order of their importance. To arrange 
them thus would be somewhat difficult. While the medical 
profession generally holds the opinion that infected water is the 
most frequent cause, the experience of some health officers leads 
them to give infected milk a very high rating as a mdium for 
the distribution of typhoid infection. Again, competent 
observers have found that, for their localities, and in the com- 
munities in which they have made their observations, " contact 
infection " has manifestly been a leading factor. 

The arrangement which I'ollows is that of presenting first and 
prominently some of the epidemic factors of typhoid fever 
which have until recently received but scant attention in this 
country. 

Contact Infection. — There is developing a close parallel 
between the three chief enteric epidemic diseases — typhoid fever, 
Asiatic Cholera, and dysentery. That will be shown in the 
appended " Notes on Dysentery and Cholera." V/hile their 
epidemic extension through the medium of polluted water has 
long been recognized, their spread from person to person as 
contagious diseases, or by contact infection " has received too 
little attention. 

In the report* which was made on the prevelence of typhoid 
fever in the U. S. military camps at the end of the Spanish Wiar 
in 1898, by the very competent commission (Drs. Reed, 
Vaughan, and Shakespeare) appointed to investigate the matter, 
are found the following: 

" Camp pollution was the greatest sin committed by the troops 
in 1898." * * * " Infected water was not an important 

* Abstract of Rpt. on the Origin and Spread of Typhoid Fever in 
U. S. Military Camps During the Spanish War of 1898. pp. 179-183. 



9 



factor." * * * It is more than likely -that men transported 
infected material on their persons or in their clothing and thus 
disseminated the disease. V/e have condemned the method 
which was followed in many of the camps of detailing men from 
the ranks to act as orderlies at the hospitals. In some of the 
commands it was customary to detail lOO or more men from the 
line every morning. These men went to the hospitals, handled 
bed pans used by persons sick with typhoid fever, and at night 
returned to their comrades. The most of these men were 
wholly ignorant of the nature of infection and the methods of 
disinfection. In fact, at one of the division hospitals we saw 
orderlies of this kind go from the hospital and partake of their 
midday meal without even washing their hands. These men 
handled not only the food which they ate, but passed articles to 
their neighbors. It seemed to us that a more certain method 
for the dissemination of an infectious disease could hardly have 
been invented." 

The medical division of the office of the P russian War 
Department* has published a work which presents the prevail- 
ing opinion at the present time among the leading authorities 
upon the subject of typhoid fever in military experience. This 
pamphlet states that great epidemics of typhoid fever are due 
to the fact that many men are exposed to the bacilli which are 
excreted by the sick. Most frequently drinking water is the 
medium through which infection is conveyed, in many cases, 
however, food which has been infected with the excretions of 
the patient is the medium of communication. The communica- 
tion of the infection often occurs as the result of personal asso- 
ciation with the sick. The infectious material may be conveyed 
by the clothing, bedding, by various utensils and articles which 
have come in contact with the sick. The rooms formerly 
occupied by typhoid fever patients may be infected so as sub- 
sequently to communicate infection to other persons. The 
spread of the disease is also favored by the pollution of the 
surface of the ground with typhoid discharges and by the want 
of local cleanliness. The early recognition of th^ first cases of 
typhoid fever which occur is emphasized as offering the possi- 
bility of preventing the further spread of. the infection. Quar- 
ters that have been vacated by the sick should be thoroughly 
disinfected, and the clothing of the patient and all the articles 
used by him must undergo efficient disinfection. 



* Deutsche Viert. f. off. Ges., XXXIII., (Sup.), 154. 1902. 



10 



A discussion on -typhoid fever before the German public 
health association in September, 1905, brought out some inter- 
esting points in regard to contact infection.* 

Drigalski said : Epidemics of typhoid fever due to contact 
are slow in their course. There is a gradual rise and fall in the 
curve of prevalence which differs from the suddenness of the 
outbreak when the infection is referable to an infected water or 
milk supply. In the latter case there is usually a sudden rise 
and a sudden fall with a smaller prevalence of the disease due 
to contact infection." 

Springfeld states : " Exacerbations of the typhoid fever 
curve which may appear periodically or irregularly are due in 
a great majority of cases to massive infection. The single cases 
of infection are due either to importation or to secondary infec- 
tions following the original infection. In industrial centers the 
imported cases are not more than 10% of the total. The single 
infections (contact infection) usually occur 4 weeks after the 
primary case and usually in the vicinity of the house where the 
first case has occurred or upon the same street. In due time the 
third series of cases may occur, and thus the prevalence of the 
disease may be continued, case linked with case, chainlike." 

The following interesting statement of opinion and of fact 
was made by Professor Fischer of Kiel : " A great number of 
cases of typhoid fever are due to contact infection. Infection 
in this way comes most frequently to the persons who care for 
the sick and quite a per cent, of the cases under my observation 
have been among trained nurses. In Kiel, for example, we had 
in the latter half of the past year only 50 cases of typhoid fever. 
Five of the hospital nurses contracted the disease. In the pre- 
ceding year one of the sisters engaged in the care of a typhoid 
patient took the disease. Two of these sisters died. It is pos- 
sible that even these trained nurses were not careful enough. 
That was shown in the case of one, but with the others there 
was no reason to assume that this was true. Our experience 
leads to the conclusion that it is difficult in the care of these 
cases to avoid the danger of contact infection. 

"I wish emphatically to state that it is not only in private 
houses that contact infection occurs, but in hospitals as well, 
where every precaution is supposed to be taken through disin- 



* Deutsche Viert. f. off. Ges., XXXVIII, pp. 22-65. 1906. 



II 



fection of the discharges and otherwise to avoid the danger ; and 
here is a point which I would suggest: whether we should not 
give the nurses who are thus endangered a protective inocula- 
tion. It is true that our experience in regard to this method of 
immunization is not great, but the question may be raised wheth- 
er, when persons are especially endangered, it may not be 
desirable thus to seek to protect them. There are other condi- 
tions under which I may be allowed to suggest the desirability 
of protective inoculations. I remember one outbreak which 
occurred this year. In a factory in which about 200 men and 
women worked within a short time, 30 cases of typhoid fever 
occurred. We were obliged to discharge these patients from the 
hospital at the earliest date. The hospital was full and it was 
impossible to retain them longer. There was nothing else to do 
but to discharge them and let them take their places again in the 
factory. In this instance a protective inoculation would have 
been in place." 

Professor Griesbach remarked : "In the discussion before this 
Association we have heard that virulent typhoid germs may be 
discharged from tlie organism weeks after convalescence. Fur- 
ther it is easily possible that children who are suffering with 
suspicious gastric or intestinal symptoms and disease of respira- 
tory organs, and are at the same time attending school, may be 
transmitters of typhoid fever. The disease may be transmitted 
through the medium of drinking cups in common use by the 
children, or through the clothing, by means of books, or other- 
wise. 

"School teachers and directors of schools should in all cases 
be promptly notified of the appearance of typhoid fever in any 
of the families in which children live who attend their school. 
It should then be the duty of the school physician to keep the 
pupils under observation who have associated with persons who 
may be the transmitters of typhoid fever. When children pre- 
sent symptoms a bacteriologic investigation of these people is 
emphatically required, and the children from the families in 
which there are cases of typhoid fever should be permitted to 
reenter school only after they have been under the observation 
of the physician and have been under bacteriologic control." 

Dr. Demuth said: "The history of an outbreak of typhoid 
fever which I will narrate has, I think, the value of a scientific 



12 



experiment. In a large ward in a hospital there occurred suc- 
cessive cases of typhoid fever in spite of the strictest precaution- 
ary measures against accidents of this kind. We were at first 
unable to discover any cause for these cases. An appeal was 
made to the Director of the Bacteriological Station to make an 
investigation. The result was that he found two patients in this 
ward wdio, in their excretions, w^ere giving off typhoid bacilli. 
These two patients were isolated and thereupon the recurrence 
of the cases of typhoid fever ceased suddenly. Two nurses 
were constantly employed in this ward, and this outbreak of 
fever in the ward was felt the more keenly because every new 
nurse who had been sent to this ward, six altogether, took the 
disease. The two patients, carriers of infection, who were iso- 
lated were put in charge of a nurse who had previously had 
typhoid fever. In the course of the summer this nurse left and 
a new nurse, assigned to duty in the barracks where these two 
patients were still isolated, came down with typhoid fever in 
three weeks. After a year had passed both of these carriers of 
infection were still excreting typhoid bacilli.'' 

Dr. Bestelmeyer, a surgeon on the general staff' of the Bava- 
rian Army, stated emphatically in this discussion: ''The peo- 
ple generally should be taught that typhoid fever is directly 
infectious, from person to person, and they must also be taught 
the danger of infection from impure water and infected milk." 

Professor William T. Sedgwick of Boston, who is widely 
known among other works for his distinguished ability in inves- 
tigating outbreaks of typhoid fever, wrote the following words 
in relation to the spread of typhoid fever in Bondsville, Mass., 
a manufacturing village where water-borne and milk -borne 
infection was excluded: 

"Children abound; and, as there are no fences, and because it 
is the custom, they mingle freely, playing together and passing 
from house to house. The families are of that grade in which 
food always stands upon the table; meals are irregular except 
for those who must obey the factory bell. The children play 
awhile, then visit the privies, and with unwashed hands finger 
the food upon the table. Then they eat awhile, and return to 
play. Or, changing the order of things, they play in the dirt 
and eat and run to the privy, then eat, play, and eat again, and 
this in various houses and in various privies. For them, so 
long as they are friendly, all things are common, — dirt, dinners 
and privies ; and to illustrate exactly how secondary infection 



13 



may go on, I may describe in detail one case which I personally 
witnessed. A whole family (of six or more) was in one room. 
Four of them have the " fever." Two of these were children in 
the prodromal stage. A table stood by the window covered with 
food, prominent among which was a big piece of cake. It was 
early September, and a very warm day ; but every window was 
shut and the odor was sickening. Flies innumerable buzzed 
about resting now on the sick people, now on the food. A kind 
hearted neighbor was tending the baby. By and by one of the 
children having the fever withdrew to the privy probably sut- 
fering with diarrhoea, but soon returning, slouched over to the 
food, drove away some of the flies, and fingered the cake list- 
lessly, finally breaking ofif a piece, but not eating it. Stirred by 
this example, another child slid from his seat in a half stupid 
way, moved to the table, and, taking the same cake in both 
hands, bit off a piece and swallowed it. The first boy had not 
washed his hands, and if the second boy suffered from secondary 
infection, I could not wonder at it. 

" This was one case : but I have seen so often the table of 
food standing hours long in the kitchen and serving as one 
station in the dirty round of lives like these, that it is easy for 
me to understand how dirt, diarrhcea and dinner too often get 
sadly confused. Personal filth is apparently the principal agent 
of secondary infection. 

" Thus far I have not even touched upon one feature of the 
life of this little community, which deserves careful considera- 
tion. There was for most or all of these houses a sewer con- 
nection for the sinks but not for the privies. Much, perhaps 
most, of the garbage found its way into the privies. These had 
been obviously in bad condition, and, from some, filthy streams 
ran down between them and the houses. In and around these 
streams the children played. Given any original imported case, 
the infection might easily have reached these trickling streams. 
Children's fingers might thence carry the germs to the food, and 
thus the journey of the germs from one living intestine to 
another be completed. Or, again, given in such a community 
an imported case and no disinfection, as was the condition here 
at first, the importer while in the early stages handles with 
unclean hands food for others ; or the clothing of such a person 
gets infected and is handled ; there need be then no difficulty in 
completing the histor}'. It follows as a matter of course." * 

Finger Infection. — That the fingers of persons attending cases 
of typhoid fever are, without intelligent cleansing and disinfec- 
tion, dangerous to their owners and to other persons, is indi- 
cated in some of the preceding, and more pointedly in the 
following quotations. 



* 24th Annual Report of State Bd. of Health of Mass. p. 736. 1892. 



14 



" With reason," Drigalski remarks, " work with the typhoid 
bacillus is considered one of the most dangerous kinds of labora- 
tory work. If for years we remain unaffected while doing this 
kind of work, we may thank the efficacy of the sublimate wash- 
ing. We have not to fear inoculation through the hands as 
when working with plague infection. The typhoid organism 
infects only by the way of the mouth." 

In an epidemic of typhoid fever in Springfield, Mass., inves- 
tigated by the local board of health and by Dr. Magrath,* 
assistant secretary of the State board of health, it was found 
that the regions where the cases were the most numerous were 
those occupied by the poorer, and in many cases, the poorest 
people in the city. Cases followed no line of water distribution, 
and there was no reason to incriminate either the milk supply 
or the ice supply. A close study of all the conditions led to the 
conclusion that the main factors in the spread of the disease 
were the many peddlers of fruit and vegetables. It was ascer- 
tained that in a number of instances cases of typhoid fever had 
been present in the families of these small venders themselves, 
and the conclusion was that the infected material being present 
on the hands of any persons, these venders or others handling 
bread or fruit, or vegetables to be eaten uncooked, the transfer- 
rence of the infection to those articles of food would be an easy 
matter. In addition to the means of spread here outlined it was 
thought that there had in all probability been operative locally 
in the spread of this epidemic transmission by means of flies. 
It is certain that in particular localities conditions existed favor- 
able to spread by this means : open vaults, broken windows, 
domestic uncleanliness, coupled with the occurrence of cases of 
the disease, furnishing all that was required for such trans- 
mission. 

In the discussion of the paper by Dr. Magrath, Prof. Sedg- 
wick said that: Of course, hand to hand, and finger to finger, 
and mouth to mouth spreading is one way in which the slow and 
insidious spread of typhoid fever can be done. He referred to 
his experience in Bondsville in 1892, in which case he attributed 
the transmission of the disease very largely to the filthy hand- 
ling of food and to the playing of children in filthy gutters 
which had been infected from houses having cases of typhoid 
fever in them. 



* Am. Jr. of Public Hygiene, XV., 467. 1905. 



15 



In another place, Professor Sedgwick and Wilson* say : 
Food, fingers, and flies ofter an alliterative summary of the 
most common agents. The one thing upon which we can fix 
our attention with certainty is the common point of departure. 
Every germ of typhoid fever, whatever its subsequent history, 
originates in the body of a typhoid patient and leaves it in the 
excreta. Every case of typhoid fever is due to the presence of 
excreta on food or fingers, or in some other place where excreta 
should not be. Filth is the fundamental condition for the 
spread of typhoid fever ; cleanliness the universal panacea for 
its eradication. 

One fact which stands out with especial clearness the longer 
we study the subject is that in spite of all that may be, and has 
been, said to the contrary, typhoid fever is a contagious disease. 
Instead of saying, as is often said, that " typhoid fever is infec- 
tious, not contagious," we need to say to-day that " typhoid 
fever is both infectious and contagious ; " and, doubtless, it is 
in part for this very reason that it has been found so diflicult to 
exterminate. 

Transmission by Clothing. — " When a command badly 
infected with typhoid fever changes its location it carries the 
specific agents of the disease in the bodies of the men, in their 
clothing, bedding and tentage. This is shown by the fact that 
when commands changed location, leaving behind them all their 
sick, and when they went to places free from the infection the 
disease continued with them. Even an ocean voyage does not 
relieve an infected command of its infection. This was shown 
in the study of the various commands that went to Cuba and 
Porto Rico. After a command becomes badly infected with 
typhoid fever changes of location, together with thorough dis- 
infection of all clothing, bedding, and tentage is necessary." f 

The British Medical Journal gives the following as the " real 
facts " in regard to an outbreak of typhoid fever which occurred 
on board the training ship " Cornwall : " 

" Ten cases of typhoid fever having occurred on the training 
ship ' Cornwall ' early in April, an investigation into its origin 
was duly undertaken; and as no other cause was found, atten- 
tion was at last directed to certain blankets recently taken into 
use. Stains on them awakened suspicion, and examination by 
Professor Klein, F. R. S., proved that the blankets were swarm- 
ing with typhoid bacilli in an active condition. The blankets 

*Jr. N. E. Water Works Assoc., XX., 51, 1906. 

t Report on Typhoid Fever in U. S. Military Camps during War of 
1898, p. 185. 



i6 



in question had been offered to the authorities of the ship at an 
unusually low rate and as the sample submitted was good, a 
considerable number were at once bought. All the blankets 
concerned were army blankets, and the question that next arose 
was how they came to be upon the market at all, whether clean 
or unclean." 

Apparently a very large number of blankets — ^many thou- 
sand — which had been used by the British troups in South 
Africa in hospitals and elsewhere were sold by the government, 
it is said at the vile price of five cents apiece, and in due course 
found their way to London, and were widely scattered."^ 

Curschmann narrates the following incident : f 
A number of years ago the following instructive experience 
occurred to me : A young merchant living in middle Germany, 
who was accustomed to send a portion of his clothing and linen 
to his home in Hamburg to be laundered, continued this prac- 
tice when attacked with " gastric fever." Ten and twelve days 
respectively after the sister of the patient and a servant had 
washed the linen, they became ill, the one with a mild, the other 
with a severe attack of typhoid fever. That the brother had 
also suffered from the same disease was unfortunately demon- 
strated by autopsy, death occurring from copious intestinal 
hemorrhage in the course of an apparently mild attack." 

" In 1886 a woman who had been called to one hamlet to 
nurse her children returned to her home, was taken sick with 
typhoid fever and communicated the disease to her nurse, and 
subsequently fifty other cases developed which could not be 
traced to soil pollution or infected water supply. From this 
locality three children were admitted to the hospital at Bonn; 
here four persons were attacked who had come in direct con- 
tact, and five washer women who had come in indirect contact, 
i. e., through the clothing and linen of the patients." J 

In the German army barracks various instances have devel- 
oped indicating that typhoid fever has been spread by clothing. 
In one of the barracks typhoid fever had for a long while been 
present. Suspicion finally fell upon the bed linen and clothing. 
It had been discovered that three of the recent cases who had 
used the clothing had been attacked with typhoid fever and the 
linings of the trousers were almost without exception soiled 
with dried fecal matter. The clothing was submitted to a thor- 

* Boston Medical and Surgical Journal, CXLVIIL, 649. 1903. 

t Nothnagel's Encyc. of Pract. Med. — Typhoid Fever Volume, p. 55. 

t Rpt. St. Bd. of Health, Iowa. 1897, p. 148. 



17 



ough cleansing and disinfection. From that time on no more 
cases of typhoid fever appeared. 

In a second history of typhoid fever in one of the German 
barracks the same results, complete cessation of the prevalence 
of the disease, followed a thorough disinfection of the clothing. 

That the bacillus of typhoid fever, dried upon ordinary 
fabrics, retains its life for a long while is evinced by experi- 
ence and experimental investigations. 

Heim* found that typhoid bacilli on silken threads retain 
their vitality 213 days in the dark. 

At the conclusion of his experimental work for the purpose of 
determining the power of resistance of the typhoid bacilli 
against drying and the possibility of their transportation through 
the air in a virulent form. Prof. Uf¥elmannf sums up his results 
as follows : 

The typhoid bacillus remains alive and virulent for at least 
21 days; in white sand for at least 82 days; in dirt for more 
than 30 days ; on linen from 60 to 72 days ; on " buckskin " 
from 80 to 85 days ; on wood for at least 32 days. 

The conditions and the results of these experiments teach that 
typhoid bacilli resist for a considerable time the influence of a 
continued drying when the action of sunlight is excluded. They 
teach also that viable and virulent typhoid bacilli in the dust 
or filth from the ground, houses, the streets, and clothing may 
be transported through the air so as to infect milk and other 
articles of food. The possibility of the transportation of infec- 
tion through the air must therefore be acknowledged. It is 
questionable, however, whether the infection can come through 
the respiratory organs, but probably may through the mouth by 
being swallowed. 

Typhoid Houses. — It has been observed that typhoid fever 
has recurred successively at intervals of months or years in cer- 
tain houses. In some of these houses the explanation is that 
the typhoid bacillus has retained its vitality a long while, some- 
times in rooms which were not disinfected after the earlier 
cases, and sometimes in polluted grounds from which nearby 
springs or wells have received drainage. A new explanation 

* Zeit. f. Hyg., L., 123. 1905. 
t Centr. f. Bak., XV., 133. 1894. 

2 



i8 



for some of these outbreaks is that persons in these houses who 
had typhoid fever continue for a long time to give off the infec- 
tion in their excretions. 

" In these cases of long continued excretion of typhoid 
bacilli/' says Drigalski, " it is not necessary to look for patho- 
logic changes in the organs. The continuous excretion of the 
infectious germs sometimes continues in persons who are 
entirely free from all signs of disease. These observations of 
mine date back to the beginning of 1903, and in two years I 
have found in 900 cases of typhoid fever 300 persons, 33% of 
the whole, who continued to excrete the typhoid bacillus for a 
period of time longer than ten weeks. In one case it continued 
for a year and a half almost in pure culture in the urine; in 
one, for more than nine months ; in two, more than seven 
months ; in one, six months ; and in seven cases, more than 
three months." 

That the floors, furniture and bedding of barracks may 
become infected and continue to be infective for a long time has 
been shown in the experiment of some of the European army 
surgeons. An instance is a report made by Chour, a Russian 
medical officer: 

Two regiments of infantry stationed at Jitomir and using the 
same water supply were unequally affected with typhoid fever. 
One showed a sickness rate of 9.6 per 1,000 in 1885, and 3.2 
in 1886 from that disease. The other regiment had at the same 
time a typhoid morbidity rate somewhat greater ; one company 
particularly was severely affected in 1886. There were 14 cases 
of typhoid fever among the ninety men. This intensive preva- 
lence in this company suggested the idea of a localized cause of 
some kind in the room where the men were lodged. In 
December, 1886, the quarters occupied by this company were 
evacuated and an energetic disinfection of the walls, floors, 
clothing and bedding was carried out. After the execution of 
these prophylactic measures, the company again occupied its 
quarters. The typhoid sickness rate was reduced to i . 7 per 
1,000 in 1887 and there were no cases whatever in 1888. Now 
it developed that during the same period of time in those rooms 
of the barracks which had not been submitted to disinfection, 
typhoid fever persisted and gave a sickness rate of 22 per 1,000 
in 1887, and 33 per 1,000 in 1888. This remarkable disappear- 
ance of typhoid fever in the rooms which had been carefully 
disinfected and its persistence in those others which had not 
been disinfected, confirmed the theory of a local cause. 

The rooms were immediately evacuated and the men were 
quartered in the woods in the vicinity of Jitomir. Three cases 
appeared among the men within the period of incubation of 



19 



typhoid fever, but after that and the disinfection and renovation 
of the rooms, the epidemic was extinguished.* 

Referring to typhoid houses Schlegtendalf narrates the fol- 
lowing history : 

" In a farmhouse each new servant who came to the house 
came down with typhoid fever, as also all the children who were 
born in this house had the disease during their childhood. How 
long back this recurrence of cases of typhoid fever had occurred 
in this house is unknown. There was a failure to discover any 
conditions which offered a solution to the cause of the continued 
presence of typhoid fever. In the nineteen cases which he 
records the interval between the succeeding cases varied from 
two months to five years." 

Typhoid Distribution by Flies. — In the report:]: on typhoid 
fever in the military camps in 1898, flies we are told, undoubtedly 
served as carriers of the infection. Flies swarmed over the 
infected fecal matter in the pits and then visited and fed upon 
food prepared for the soldiers at the mess tents. In some 
instances where lime had recently been sprinkled over the con- 
tents of the pits, flies with their feet whitened with lime were 
seen walking over the food. 

It is possible for the fly to carry the typhoid bacillus in two 
ways. In the first place, fecal matter containing the typhoid 
germ may adhere to the fly and be mechanically transported. In 
the second place, it is possible that the typhoid bacillus may be 
carried in the digestive organs of the fly and be deposited with 
its excrement. 

Dr. Potter, § medical oflicer of health of Chemnitz, Germany, 
told of an outbreak of typhoid fever which appears to have been 
due to transmission of infection by flies. 

" While in Leipzig there was a tenement house in one of the 
suburbs of Leipzig in which in rapid succession eight cases of 
typhoid fever were reported all which occurred in one-half of 
the house. There were two tenements on each floor. In the 
two tenements on the north side of the house the typhoid fever 
occurred. In the tenement in the other end of the house there 
was not a single case. Each tenement had its own privy. In 
the tenement in which the cases of fever were found the privy 
was located just off from the kitchen. For the tenement in the 

* Traite de "Medicine, II., 51, 1899. 

t Zeit. f. Med. Beamte, XVI., 641, 1903. 

t Report of Drs. Reed, Vaughan and Shakespeare. 

^Deutsche Viert. f. dif. Ges., XXXVIIL, 64. 1906. 



20 



other end of the house there was no direct communication 
between the privy and the hving-room. When the cover of the 
privy in the north part of the house was opened a swarm of 
flies always came up. Some of the flies were sent to Prof. 
P ischer in the laboratory of the Hygienic Institute of Leipzig, 
and typhoid bacilli were found in these flies in large numbers. 
His investigation showed that the typhoid bacilli which had 
been eaten by these flies retained their vitality for a period of 
twenty-three days. 

Dr. A. W. Martin,* medical health officer of Gorton, England, 
referring to figures which he gives relating to diarrhea says that 
they give every indication that there is a cause operating during 
the warm months of the year and which is absent during the 
colder parts. " Since 1898 I have tried to show year by year 
in my annual reports, the connection between this disease and 
the domestic fly. A hot, dry summer produces an abundance 
of flies and diarrhea makes its appearance in about a week 
after the flies appear in large numbers. The diarrhea sickness 
fluctuates and keeps pace with the temperature of the atmos- 
phere, which is much influenced by the rainfall, and also the 
number of flies keep pace with the temperature of the atmos- 
phere and the rainfall. The atmospheric changes are but 
secondary cuses in the producing of the disease, namely as 
influencing the appearance and disappearance of the common 
house fly, and also as affecting their numbers. During the 
summer a privy vault was examined at the house of a typhoid 
case ; the flies were hanging in bunches and wading and sucking 
up the liquid excreta, flying directly into the kitchen, into milk 
vessels, and onto food exposed on the table." 

In a report made by a committee of experts appointed to 
investigate the source of infection in an outbreak of typhoid 
fever in the jail of New Haven county, Connecticut, it is stated 
that typhoid attacked only the prisoners, twenty cases in all. 

Neither did they find any evidence that the character or 
quality of the food in itself was chargeable with the outbreak. 
They found, however, that the food was sometimes exposed for 
a little while on tables; the windows of the apartment being 
opened and not screened, it was readily accessible to flies. 
Having found no satisfactory evidence that the infection had 
been introduced into the jail in water, milk or other ai tides of 



* Public health, XVII., 711. 1905. 



21 



food, their attention was given to the discovery of any sources 
of infection in the vicinity outside the jail. 

It was found that in the adjoining street there were f^ve dwell- 
ings adjoining the jail property in which cases of typhoid fever 
had occurred from the 22d of August to the 17th of September, 
and that the privies in the rear of these houses were in a very- 
foul condition, " and in several instances fecal matter was found 
lying exposed on the surface of the ground." 

It was the opinion of the committee that the occurrence of 
cases of typhoid fever in adjacent houses had infected their 
filthy privies, and the abundance of flies with the open com- 
munication through the window^s between the kitchen and the 
adjoining yards, was in all probability the method of transmis- 
sion of infection. 

Sangree, after calling attention to the enormous number of 
flies present at the military camps where typhoid epidemics 
occurred, gives the results of some experiments he performed, 
which were designed to show^ the ability of flies to carry infec- 
tion. He allowed flies to remain half a minute on an agar culture 
of anthrax bacillus in a Petri dish ; he then placed them upon a 
sterile agar plate, and found that at every point where the fly's 
foot had trod anthrax colonies developed. The, same was also 
shown on potato. It is reasonable to suppose that the same 
results could have been obtained with the typhoid bacillus.* 

Danger From the Sputum. — The exhaled air from the lungs 
of the typhoid fever subject is germ free, as it probably is in all 
infectious diseases. There is therefore no possibility of this 
disease being spread by means of the air exhaled from the lungs. 
This statement is true only when the exhaled air is free from 
sputum. In the pneumonias that complicate typhoid fever the 
Eberth bacillus is found in the diseased lungs and may be elim- 
inated m the matter coughed up and disseminated through the 
air in the fine spray that accompanies severe fits of coughing. 
However, the spread of typhoid fever in this manner must be 
regarded as a bare possibility.f 

Dr. P. W. Williams, i assistant physician to the British Royal 
Infirmary, reports five cases of typhoid fever as tending to prove 

* Med. Record— Maryland Med. Jr., XLIIL, 19. 1899. 
t Rept. of Reed, Vaughan and Shakespeare in U. S. Military Camps 
in 1898. 

% British Med. Jr., 1892, Vol. II., p. 1353. 



22 



that this disease may be communicated by the breath, or expec- 
toration of infected persons. 

In the first case the patient was dehrious, and for some days 
had a good deal of laryngeal and bronchial catarrh, and was 
constantly coughing and expectorating about the bed. Later 
there was a relapse with symptoms of acute laryngitis. The 
autopsy confirmed the diagnosis. The lungs were extremely 
congested and the lower lobes of both lungs were consolidated. 
Typhoid ulceration in larynx. He was admitted to the Royal 
Infirmary on the sixth day of his illness. 

Cases two and three were brothers of the first case. They 
were removed to the Bristol Union Workhouse. Their disease 
was of a severe type, but there were no special laryngeal 
symptoms. 

The fourth case was the nurse who attended the first case in 
the Infirmary. She died. 

In the fifth case, it was thought the man contracted the dis- 
ease from the first patient who had the laryngeal complications. 
This fifth case was a fatal one, and, post-mortem, the bacilli of 
typhoid fever were found in the typhoidal ulcerations which 
were present in the larynx. 

In investigating the sputum of eleven typhoid patients bron- 
chitis was present in ten, and in one pneumonia developed. In 
this last patient the typhoid bacillus was present in the sputum 
for a period of ten days. Edel,* who observed these cases, 
advises that the sputum of typhoid patients be disinfected with 
solutions of carbolic acid or lysol. 

Typhoid bacillus was also found by Dieudonnef in the expec- 
toration of a typhoid fever patient. The disease first assumed 
the form of a pneumonia but later clinical symptoms of typhoid 
fever presented themselves with the typhoid spots and enlarg- 
ment of the spleen. Widal reaction was also positive. Typhoid 
bacilli also were present in the sputum seven weeks after the 
patient was received at the hospital and after the patient felt 
entirely well. 

From Wells and Springs. — The history given by Dr. Austin 
Flint, Senior, of an outbreak of typhoid fever in the village of 



* Fortschr. d. Med.— Viert. f. dff. Ges., XXXIV., 140, 1903. 
t Centr. f. Bak., XXX., 481. 



23 



North Boston, N. Y., in 1843 was one of the important pieces 
of work which furnished indubitable proof of the agency of 
polluted water in spreading typhoid fever. He says : 

The fever was at first imported to that place by a young 
man from some place in Massachusetts, who, arriving at North 
Boston by stage, took lodgings at the tavern on the 21st of 
September, where he died on the 19th of October, 28 days after 
his arrival. 

In this little hamlet were nine families, consisting of 43 
persons. Between October 14th, five days before the date of 
the death mentioned, and December 7th (twenty-one days), 
twenty-eight of the forty-three persons comprising this little 
community, were attacked with the fever, and in ten instances 
the disease proved fatal. 

" An important part of the history of this epidemic, says Dr. 
Flint, remains to be stated. At the time of writing the report 
from which the foregoing extracts are taken, and for many 
3^ears afterwards, — indeed, up to a recent date, — I had no idea 
of the diffusion of typhoid fever through the agency of drinking 
water. At the time of the epidemic nothing had been published 
on the topic, and at the time of writing this report, and long 
afterwards, I was not aware that any one had entertained this 
view of the causation, — there was nothing relating to it in the 
medical literature of the country. 

" All of these nine families but three used water for drinking 
and culinary purposes from the same well, — that belonging to 
the tavern. Two of the three families not using it, did not on 
account of their distance from it, and the intervention of a 
stream some three or four rods wide. Their intercourse, how- 
ever, with the others was free and familiar. The other family 
who did not use the water was at enmity with the proprietor of 
the tavern, and had been forbidden its use. 

" So strongly did the circumstances at that tim^e seem to point 
to the tavern well, as the source of the contagion, that suspicion 
was aroused and charges of poisoning the well were openly 
made against the family who, alone in the immediate vicinity 
of the well did not use of its waters, and did not suffer from the 
disease. 

" It can hardly be doubted that the exemption from the dis- 
ease of the family of Stearns (who did not drink the water), 
was due to the animosity of the inn-keeper, which led the latter 
to prohibit the use of his well, and compelled Stearns to dig a 
well of his own. The two families living forty rods from the 
tavern escaped because, owing to the distance, they did not 
obtain water from the inn-keeper's well. 

At the time of the epidemic no suspicion of the presense of 
the special cause in the drinking water being entertained, pains 
Avere not taken to note the situation of the privies, the nature of 



24 



the soil, etc. In order to obtain some information on these 
points I wrote recently to Dr. P. Barber, at the date of the 
epidemic, and until lately, a practitioner in that neighborhood. 
Dr. Barber writes that, according to his recollection, the privy 
attached to the inn was three or four rods from the well, and he 
recollects that the contents were allowed to accumulate. The 
vv^ell was by the road-side, supplying with water the inn and the 
stables, as well as the immediate neighbors." * 

The history of the North Boston outbreak is cited as one of 
the important early observations. Since then innumerable 
observations have been made which show plainly the dangerous 
character of polluted well water. 

The following may serve as a late instance. It is related by 
George A. Soper,f as a part of the aftermath which followed 
the outbreak of typhoid fever in Ithaca, N. Y. It was the 
result of the contamination of a well on the property of a man 
named Barnes. The Barnes well had been famous ; people 
who had learned to fear the city water went to the Barnes well 
with a feeling of perfect safety. No one had ever been made 
sick from drinking this water. So great was the demand upon 
the well that the water was actually piped to another house. 
Many of the people who had been drinking from the Barnes 
well were taken ill. In all there were fifty cases of typhoid and 
five deaths traced to this well. 

" When suspicion was directed to the well, I visited it and had 
the drain pipe from the water closet in the Barnes house exca- 
vated. The drain ran within three or four feet of the well. 
When the laborers dug the earth from beneath the drain, they 
found that the joints had been scamped; that is, insecurely and 
improperly closed. When the water closet in the Barnes house 
was flushed, the water would run through the drain to a point 
about ten feet from the well, whence it would flow out into the 
porous soil through the leaky joint and so into the well. On 
analysis, the water of the well was found to be grossly polluted. 

" We needed, however, to find out how the drainage which 
entered the well had actuUy infected it. It was then discovered 
that Mrs. Barnes had suffered, some weeks before, with a mild 
attack of typhoid fever, which had been pronounced by her 
physician to be grippe. We proved the real character of her 
disease by taking a specimen of her blood and examining it in 
the laboratory. The dejecta from this patient passed down 
through the water closet without disinfection; it escaped from 

* Third An. Rpt, State Bd. of Health of Mich., p. 64. 
tJr., N. E. Water Works Assoc., XVIII., 445. 1904. 



25 



the drain pipe into the well and, as we have said, occasioned 
fifty cases and five deaths." 

Konradi* refers to a remarkable epidemic of typhoid fever in 
a village containing 450 inhabitants, in which during the first 
week of the epidemic about forty cases appeared, and within six 
weeks the total number had run up to 200. The infection was 
traced to the well in the market-place and used by all the people. 
A man came from another village infected with typhoid fever. 
He dwelt near the well and it could be shown that the soakage 
from the dejections which were emptied upon a pile of manure 
could easily find its way into the well. The well was closed and 
the epidemic soon ended. 

Dr. C. O. Probst, Secretary of the State board of health of 
Ohio, gave the history of an outbreak of forty cases of typhoid 
fever with five deaths in a little town of four hundred or five 
hundred inhabitants in that state. There was a stone quarry 
about half a mile from the center of the village. A peculiarity 
of the geological formation was that it consisted of limestone 
ledges and this limestone was cracked in all directions, readily 
admitting a flow of water for a long distance as we discovered 
by experiment. The stone quarry, which was 26 feet deep by 
measurement — a little deeper than the wells — was being pumped 
out when I arrived at the village. When it was completely 
emptied of water, the wells for three-quarters of a mile were 
either entirely dry, or drained to a depth of two or three feet, 
there being very little water in the wells at that time. I found 
that they had had three cases of typhoid fever in the spring of 
this year. This happened only a month ago. The board of 
health, on the appearance of typhoid fever, ordered a cleaning 
up of the town. It was found that two barrels of night soil 
had been taken out and thrown into the stone quarry. This was 
discovered when the stone quarry was pumped dry. When the 
wells became lowered by the drouth there was evidently a flow 
of water from the stone quarry into the wells of the village, 
and the cases of typhoid fever commenced. I think, said Dr. 
Probst, many facts might be mentioned to show that it is pos- 
sible in certain sections, where we have a peculiar geologi- 



*Centr. f. Bak. (Orig.), XL, 3i- 1905. 



26 



cal formation, for the wells to be polluted by cesspools or privy 
vaults, thus causing typhoid fever.* 

A similar geologic formation exists in some parts of this 
State, notably in sections in Aroostook, where in one instance a 
new cellar dug and blasted into a ledge was nearly filled with 
water by a heavy shower, but it all disappeared downward 
through the ledge before the next morning. 

The historic example of Paris illustrates the danger of the 
transmission of infection long distances beneath the surface of 
the earth in certain geologic formations. In the French capi- 
tal there was a very high death-rate from typhoid fever from 
1 88 1 to 1890. 

The water for the city was obtained from the Vanne, the 
Avre, the Dhuis and the Lunain. The earth in the region from 
which these sources of supply were located consisted of chalk 
in which in all directions there was a plentiful network of con- 
necting cracks and rifts. This chalk is covered with a thin 
layer of clay and gravel. Through these rifts in the chalk the 
ground water circulates freely and here and there comes to the 
surface in the form of springs. The water which circulates in 
these subterranean passages, on account of its large quantities 
of carbonic acid, dissolves the openings in the chalk thus con- 
tinually widening them. Thus there has resulted the formation 
of veritable subterranean brooks and streams. This enlarge- 
ment of the fissues in the chalk leads finally to the formation of 
caverns, the roof of which is formed by the strata of clay and 
gravel. Where these roofs have fallen in sinks or holes in the 
ground result. All the surface water which reaches these sub- 
terranean galleries comes to the surface in the springs without 
sufficient filtration. This water is clear, cool, and of unobjec- 
tionable taste. By pouring into these sunken places fluorescin, 
lycopodium, and one of the yeasts, the connection between these 
springs and these caved-in places was demonstrated, a fact 
which a knowledge of the geological formation had previously 
indicated. Fluorescin was also poured into holes bored in the 
earth at various places. By this means the extent of the ground 
surface which fed the particular springs was determined. The 
rapidity with which the coloring matter made its way in these 



* Rpts. and Papers of the Am. Pub. Health Assoc., XIX., 265. 1893. 



27 



subterranean water-courses varied from 90 to 100 meters in an 
hour. By the method of Cambiers the drinking water of the 
city was examined every 3 days, and that of the springs daily 
for typhoid bacilh. After a small outbreak of typhoid had 
occurred upon the drainage area of the Vanne, typhoid bacilli 
were found in the reservoirs fed from these sources.* 

The degree of the danger of the infection of wells from 
sources of pollution on or in the ground surrounding wells 
depends largely upon the character of the strata entering into 
the composition of the ground. When it is, for some consider- 
able distance downward, finely granular and homogeneous in 
structure, sand or sandy loam for example, there is less danger. 
In coarse sand or gravel, the filtering action of the soil can less 
be trusted. The danger is intensified by the presence of seamy 
ledges, or where there is rather a thin soil overlaying an 
impermeable stratum of rock or clay. 

Life of the Typhoid Bacillus in the Ground. — The following 
observations relating to the life of the typhoid bacillus has an 
important bearing upon the question of the infection of wells, 
springs, and other water supplies. 

Levy and Kayserf published the following observations bear- 
ing upon the duration of the life of the typhoid bacillus. 

On the 8th of September, 1901, in the . evening, Herrb 
returned from a journey to S., a suburb of Strasburg. He was 
then not feeling well, but did not call a physician until the 
13th. As his physician suspected typhoid fever he immediately 
ordered the disinfection of the stools. On the 15th of Septem- 
ber the patient was transferred to the hospital. The dejections 
of the patient had been emptied into the privy vault which is a 
water-tight cement vault. From the 8th of September in the 
evening until the 13th at noon the dejections were not disin- 
fected. The vault was emptied February 6, 1902, and the con- 
tents were spread upon the surface of a garden. In samples of 
earth taken from this garden on the 20th of February the 
typhoid bacillus was shown to be present. The typhoid bacillus 
had therefore endured exposure to the sun and atmosphere and 
winter temperature 5 months in the vault and 14 days upon the 
surface of the ground. From the 6th to the loth of February 
there were frequent storms, partly rain and partly, snow. 



* Hygienische Rundschau, XIII., 105. 1903. 
tCentr. f. Bak. (Orig.), XXXIII., 489- 1903- 



28 



The following notes are taken from a paper by ProL 
Almquist* of Stockholm, upon the question of the preservation 
of pathogenic bacteria in manure heaps. 

The first time that I succeeded in cultivating pathogenic 
micro-organisms in polluted earth I took the earth from the 
entrance of a cow stable. The sample there taken consisted of 
stone, sand, and loam plentifully mixed with manure. Later 1 
made use of a sample taken near a pigpen and from near a 
slaughter-house which possessed similar characters. 

Hitherto I have used only manure which has been composted 
for some time so that it was black and humus-like. The earth 
was sterilized in an autoclave at a temperature of 120° C. Only 
distilled water was added. Some of my investigations show 
that the typhoid bacillus at the temperature of 24° C. in manure 
or earth varies in its degree of development. In many cases- 
the maximum point of multiplication was reached within the 
first week ; in other cases it was two weeks before this point 
was reached. 

The bacteria of typhoid fever, cholera, and dysentery grow 
with particular luxuriance in old well-rotted manure and in 
earth which has been manured. Their multiplication is some- 
times, indeed, more plentiful than in ordinary peptone bouillon. 
I assume that it is possible, after these disease germs have 
reached the maximum of vegetation, that their existence may 
be continued. This has been shown for sterilized manures. In 
samples which are not sterilized, the development of the flora 
and fauna is enormous — bacteria, streptothrix, protozoa, of 
various varieties constitute a lively wirrwarr in which I have 
not yet succeeded in determining the fate of disease germs. 

At the present stage of our konwledge I maintain that the 
theory is correct that the germs of typhoid fever, cholera, and 
dysentery when distributed m drainage from manure heaps and 
in earth which has been manured can multiply. If this is cor- 
rect the specific germs of these three diarrheal diseases have 
two culture fields where they may thrive : in the human digestive 
organs and in the fertilized surface soil near our dwellings. 

The experiments of Almquist show the following facts : 

That in fertilized earth as well as in pure manure after its- 
sterilization and the addition of a sufficient quantity of water, 
the specific micro-organisms of cholera, typhoid fever, para- 
typhoid, dysentery, and bacterium coli multiply at various tem- 
peratures. 

The multiplication of typhoid bacilli reaches its maximum point 
more slowly at 24° C. as a general rule than at 18° C. The max- 
imum point of the curve is sometimes not reached earlier than- 



* Zeit f. Hygiene, LII., 179. 1906. 



29 



two weeks. By the addition of 2 or of common salt the 

growth of the cholera and typhoid bacteria is luxuriant and the 
maximum point of multiplication is more quickly reached. The 
virulence of typhoid and cholera bacteria may remain unim- 
paired in manure heaps and polluted earth for several weeks. 

The biolog}- of these pathogenic germs as well as their 
€pidemiolog}^ justifies the theory that these micro-organisms 
have the power of multiplication outside of our dwellings in the 
damp or aqueous portions of manure heaps and of polluted soils. 

For several years, the ^ledical Officer of the Local Govern- 
ment Board of England carried on experimental work for the 
purpose of determining the period during which the typhoid 
bacillus retains its vitality in the soil. Dr. Sidney !vlartin* 
commenting on his two previous reports on this subject says, 
that the general conclusions to be derived from the previous 
^vork are : 

1. That in sterilized garden soils and in sterilized soils from 
the entourage of houses, i. e., in what may be called organically 
contaminated soils, the typhoid bacillus lived and multiplied, 
whether the soil were kept at a uniform tem.perature of 37^ C, 
at the temperature of the laborator\- (between 15° and 19^ C), 
or at the temperature of an outside shed (between 3^ and 
15= C). 

2. That in these soils the bacillus was still alive after 404 
days, and that for a short period it retained its vitality after the 
soil had been so dried that it could be readily reduced to a 
powder. 

3. That in virgin soils, soils which had never been manured 
or cultivated and which consisted chiefly of sand or peat, the 
bacillus did not grow nor live ; that in the majority of cases, 
even on the day following inoculation of the soil with the 
bacillus, no evidence of its presence in the soil could be obtained. 

In experiments with unsterilized soils the doctor was almost 
invariably unable to find the typhoid bacillus after a ver}- short 
lapse of time. But in one implantation of natural, unsterilized 
soil the typhoid bacillus was recovered after fifty days. 

Dr. Robertson of England, showed that when typhoid germs 
were sown into earth soaked with animal filth, the germs can 
live through the winter and the next year may multiply so that 
an area containing filth may probably remain infected from 
year to year. 

Under the inspiration of former investigators Rullmann went 
over practically the same ground as Martin in his experiments. 
He mixed loam with equal parts of fine-grained gravel. A 



28th Annual Report, Loc. Gov't Board, Rpt. of Med. Officer, p. 382. 



30 



part of the samples were sterilized, others were not when they 
were exposed to the diffused light in a room. Although the 
vessels containing the samples were larger than those used by 
Martin the typhoid bacilli had penetrated all parts of the masses 
of the earth at the end of one month. In one sample these 
micro-organisms were present nine months, and in another 
sixteen months after inoculation. They were present nearly a 
year in one sample which consisted mostly of red river sand. 
In the unsterilized samples of humus and fine gravel typhoid 
bacilli were quickly destroyed. In another variety of earth 
typhoid bacilli were found for a period of loo days. The 
diversity of results obtained by Rullmann were by him ascribed 
to the chemical action of earth of different compositions. 

Wurtz and Bourges determined by their experiments that 
pathogenic micro-organisms which were put upon the surface 
of the ground or inoculated at a depth of ten centimeters 
appeared upon the leaves and the stems of plants growing in 
this earth, a fact which had already been determined regarding 
tetanus germs. In spite of the bactericidal power of direct 
sunshine and the washing of the plants by the rainfall they 
showed that plants may be transmitters of infection. 

In the experiments of E. Pfuhlf the typhoid bacillus remained 
alive in damp garden earth 88 days, and in dry sand 28 days. 

A young woman returned from Ulm to her home village of 
Riedheim, sick with typhoid fever. Her dejections were 
thrown upon a pile of manure. After a period of five weeks 
it was carted away and four of the five persons who were 
engaged in this work came down in due time with typhoid 
fever. In like manner the dejections of these patients were 
thrown upon another manure heap and nine months later the 
manure was hauled away. Of the men who were employed at 
this w^ork all came down with typhoid fever who had not 
already suffered an attack.:): 

The history of this outbreak is sometimes referred to as indi- 
cating the trarsmissibility of typhoid infection through the air. 
It may not prove this, for the hands may have been the medium 
of transmitting the infection to the mouths and intestinal canals 
of these laborers. It does, however, appear to show that the 
infection of typhoid fever may retain its vitality and its viru- 
lence for a long time in material of this kind. 

* Cited by Levy and Kayser— Centf. f. Bak. (Orig.), XXXIII., 489. 
1903. 

t Zeit. fiir Hygiene, XL., 555. 1902. 

t Real-Encyclopadie der Gesam. Heilknnde. Band I., 13. 1880. 



31 



The results of the experimental work which has been cited 
together with those of earlier work, when the methods of identi- 
fying the typhoid bacillus had not reached that stage of certi- 
tude which now exists, are confirmatory of the conclusion 
which has been drawn from the study of epidemics, that earth 
which contains much dead organic matter — polluted soil — 
when once infected with the typhoid bacillus may retain that 
infection in a virulent form for months, and perhaps for years, 
contributing a share of its infection now and then to near-by 
wells, and possibly in other ways endangering human beings. 
The recognition of this latter possibility does not by any means 
require the acceptance of Pettenkofer's theory. 

But, in favor of the well as a source of water supply in rural 
life, it may be said that, in most parts of this State, good, pure 
water may be obtained from the ground if the well is properly 
constructed and is sufficiently distant from manifest sources of 
pollution. 

From Public Water Supplies. — How the infection in the 
stools of one typhoid fever patient may infect a large number of 
persons and thus give rise to a frightful epidemic was strikingly 
shown by the outbreak in Plymouth, Pa., the lesson of which is 
worth repeating, again and again. 

From early in January until early April a man was sick with 
typhoid fever at his home near the banks of the stream and 
above the intake which supplies Plymouth with water. 

During the course of his illness, his dejecta passed at night, 
without any attempt at disinfection, were thrown out upon the 
snow and frozen ground, toward and within a few feet of the 
edge of the high bank, which slopes precipitousl}^ down to the 
stream supplying the town with water. 

The nurse in charge states explicitly that in emptying the 
chambers at night she did not stand on the porch to throw out 
the contents, but stepped down some distance and threw them 
toward the creek. If she stepped but a few feet away from the 
porch, she would empty the excreta within twenty-five or thirty 
feet of the edge of the stream. 

The dejecta passed during the day were emptied into a privy 
a little farther back, the contents of which lie almost upon the 
surface of the ground, and at the first thaw or rain they too 
would pass down the sloping bank and into the stream. These 
dejecta were thrown ont from time to time until the accumula- 
tion no doubt equaled the daily passages from many such 
patients. They remained innoxious upon the snow and frozen 



32 



ground until sometime between March 25 and April i, when 
they were washed into the stream and thence into the third res- 
ervoir.* 

The result of this deplorable want of regard for the safety of 
the public was 1104 cases of typhoid fever, — 713 cases in April, 
261 in May, 83 in June, 31 in July, 15 in August, and one in 
September. The intensity of the infection, or the large dose of 
it received by the earlier victims, was shown by the gravity of 
the earlier cases, — high fever and delirium, severe and repeated 
intestinal hemorrhages, extreme prostration, slow convalescence, 
and tendency to relapse. 

This is a good example of an explosive outbreak of typhoid 
fever — that is, of the sudden attack of many persons within a 
short time. This was undoubtedly due to a massive infection 
of the water. The mountain stream from which the water sup- 
ply was taken, is small. The spring rains suddenly washed into 
it the accumulated discharges of the typhoid fever patient. 

Dr. Springfeld,t in a discussion before the meeting of the 
German public health association last year said : 

" We think of water infection only when a large number of the 
users of the water suddenly become sick, but my experience 
shows that the appearance of the disease due to water-borne 
infection may be sudden or gradual, depending upon the degree 
of infection of the water. The number of persons infected does 
not depend alone upon the degree of pollution. Much probably 
depends upon the virulence of the culture. Even in cases where 
there appears to be a gross pollution or infection of the water 
only a small per cent, of the persons who use the water may be 
attacked. The remainder appear to be immune either as the 
result of a previous attack of typhoid or otherwise." 

A recent outbreak fully as severe but not falling quite so sud- 
denly, was the one which they had in Ithaca, N. Y. 

As the result of indifference through a series of years to the 
dangerous condition of its water supply, a frightful epidemic of 
typhoid fever appeared in that university town in the first quar- 
ter of the year 1903. With a population given by the last cen- 
sus as a little over 13,000, it is estimated that 1,350 cases of 
typhoid fever occurred, with 82 deaths in a little more than 
three months. No less than 522 homes were visited with the 



* First An. Rpt. St. Bd. of Health of Pa., p. 176. 1885. 
i Deutsche Viert. f. off. Ges., XXXVIIL, 45. 1906. 



33 



disease; in over 150 of these there were two or more persons 
Attacked. Dr. George A. Soper/-^ consulting engineer and san- 
itar}^ expert of Xew York City, who was employed to investi- 
gate the outbreak, says that there was no doubt that the drinking 
water supplied by the \\'ater Company was the original cause 
of the outbreak, but it was evident that the disease was transmit- 
ted from person to person through carelessness and ignorance in 
nursing the sick. 

Dr. AVilham R. Stokest leports from the Bacteriologic Lab- 
oratory of the State of ^Maryland an outbreak of typhoid fever 
which occurred in a city with about 12,000 persons, in which one 
side of the city was in one state, and the other side was in a 
neighboring state. Each half of the tovv'n had a separate water 
supply. In the north side of the city practically no fever 
occurred. The towns were divided by a certain street, and it 
was said that the line of demarcation between the infected and 
the non-infected portion of the city was a striking feature of the 
outbreak. The infected part of the town received its water sup- 
ply from a spring in a hollow, while the uninfected portion was 
supplied with water from a spring some distance away in the 
hills. The bacteriologic examination of the water of the 
infected half of the city showed the presence of 9,600 bacteria 
per c. c. and the presence of the colon bacillus. 

This outbreak remunds one of the epidemic of cholera in Ham- 
burg, Germany, in 1892. Hamburg with its polluted and 
infected water supply from the Elbe, had an epidemic of 
18,000 cases of cholera, and 8,000 cholera deaths, while Altona 
had comiparatively few cases. In Hamburg 1.3 % of its popu- 
lation died of cholera but in Altona the percentage of deaths was 
only 0.2 %. They both lie upon the same side of the Elbe, and 
are practically one city, as intimately coalesced geographically 
as are Brookline and Boston, Mass., and much more so industri- 
ally. Both cities took its water from the Elbe, Hamburg 
above the two cities, but where the sewage pollution was 
undoubtedly carried to the intake by tidal flow, Altona from 
below both cities where the sewage hugs the shore. Altona, 
however, had a good modern system of water filtration which 
conferred her comparative immunity. 

*Jr., X. E. Water Works Assoc., XVIIL, 431. 1904. 
t Jr. of Am. Med. Assoc., XLIV., 595. 1905. 
3 



34 



Tavel* reports the following instructive instances of local 
infection of a water system with typhoid bacilli whicfi 
occurred in the city of Olten. This city takes its water supply 
from the Jura, and Tavel designates this water bad. In the 
second half of October, 1900, at a time when the water supply 
did not equal the demand, twenty cases of typhoid fever 
occurred in the higher lying parts of the city. As the outbreak 
occurred suddenly the water supply was suspected. Infection 
at the intake was excluded, but there was a suspicion of infec- 
tion within the limits of the city. The water in the mains is 
under high pressure, from 5 to 7^ atmospheres. When water 
was drawn there followed in the higher laying quarters of the 
city a strong backward movement of the water in the pipes. 
The water in a stationary washtub, for example, which happened 
to be connected with the faucet at the time the water was drawn 
elsewhere, was withdrawn from the tub by aspiration, the con- 
necting hose acting as a siphon. Thus polluted water found its 
way into the water mains in the locality \yhere most of the cases 
occurred. There was a man sick with typhoid fever who. a 
little while before the sudden outbreak, had returned from the 
Paris Exposition. From this place they think that, in such a 
way as has been indicated, typhoid infection was received into 
the mains, when the water pressure in this part of the city was 
absent. Among the persons who became sick in October there 
was a child, G. L. While elsewhere in the city from that point 
of time on, no further cases of typhoid fever occurred, in the 
family where this child lived there were seven additional cases. 
This child became sick October 30, and died December 5. 
December 7 the child's grandmother was taken sick and was 
sick until January 2. The mother took her bed December 23, 
but had already been ailing for two weeks. She died January 8. 
Then there was a pause in the outbreak. March 16, 1901, a son 
in this family became sick, and April 12, the servant girl. April 
16, a niece, and three weeks later the nurse who on April 18 
had taken the place of the niece who hitherto had acted as nurse. 
These persons had, in spite of emphatic commands not to do so, 
used unboiled water. Those persons only in this household who 
abstained from the using of unboiled water remained free from 



* Center, f. Bak., (Orig.), XXXIIL, 166. 1903. 



35 



typhoid fever. In this house and the surroundings there were 
the best sanitary conditions. Just below the house occupied by 
this family there was stretch of water main ii^^ meters long 
which served as a " dead end." In this piece of pipe there could 
have been but little circulation. In other words, the water was 
stagnant, although in the house of L. when the water was drawn 
it is likely there was some movement of water from this dead 
end. April 29 and 30 the end of this pipe which was closed was 
opened, and the filthy water which was found in it was exam- 
ined bacteriologically. Aside from colon, proteus, and fluores- 
cens bacilli and Staphylococci, the typhoid bacillus was found. 
Tavel considers this, the finding of the bacillus under these 
circumstances and in this place, significant as indicating that 
the typhoid bacillus under certain conditions may retain its 
vitality and its infectious characteristics for several months in 
water. 

The Vitality of the Typhoid Bacilhis in Water. — The ques- 
tion whether the use of polluted water, or water which 
receives sewage, will produce typhoid fever has many times 
been answered afiirmatively by the results of the experi- 
ments to which man has subjected himself or to which he has 
been subjected by his municipal governments. Aside from 
these, much work of a scientific character has been done for the 
purpose of determining the action of waters of various kinds, 
and of sewage upon the typhoid bacillus. Only a little of the 
literature of this work is here cited. It shows the general trend 
of results, that is, that the bacillus of typhoid fever remains 
alive under varying circumstances for periods ranging from a 
few days to many. In research work of this kind the same diffi- 
culty is met in the search for the bacillus in natural, unsterilized 
water which is encountered m seeking it in unsterilized soil — 
the overwhelming growth of micro-organisms which find their 
natural habitat in these waters. 

The experiments of Laws and Andrews for the London 
County Council indicated that the life of the typhoid bacillus in 
sewage is brief. The expermients of Dr. Klein for the Local 
Government Board confirms the observation that the typhoid 
bacillus, kept in ordinary fluid sewage, has not only no tendency 
to multiply, but, on the contrary, diminishes in numbers and 
ultimately dies. On the other hand, these experiments show 



36 



that the bacillus coli retains for a long time in sewage its vitality 
and its power of self-multiplication. 

The thought occurred to Dr. Klein that the vitality of the 
typhoid bacillus in sewage may not be parallel to its vitality in 
sewage plus water of one and another sort, as under the natural 
conditions in which typhoid fever is disseminated. In his 
experiments, he found that when a certain quantity of nitrates 
were added to the sewage, it had a tendency to prolong the life 
of the typhoid bacillus and even to increase their number. Thus 
in one of the experiments, after eight weeks, the number of 
colonies of the typhoid bacillus had increased from 16,000 to 
1,600,000. 

He also found that water from the public water supplies of 
London after it had received a trace of nutritive material showed 
the presence of typhoid bacilli at the end of eight weeks.* 

Jordan and Russellf were employed by the Sanitary District 
of Chicago to conduct some experiments upon the life of the 
typhoid bacillus in the waters of Lake Michigan, the Chicago 
Drainage Canal, and the Illinois river. The statement of their 
conclusions at the end of their paper is to the effect that under 
conditions that probably closely simulate those in nature the 
large majority of typhoid bacilli in the several waters studied 
perished within three or four days; that it is theoretically pos- 
sible that specially resistant cells may occur which are able to 
withstand for a longer period the hostile influences evidently 
present in water. Their experiments, however, show that if 
such resistant individuals exist they must be very few in number 
and constitute only a small fraction of the bacilli originally 
entering the water. They state that it is not their intention to 
claim that the behavior of typhoid bacilli under the conditions 
which were described is representative of all conditions obtain- 
ing in all natural bodies of water. 

Russell and Fuller^ of the Wisconsin State Hygienic Labora- 
tory, in their experiments in testing the longevity of the typhoid 
bacillus found that, when exposed to the action of flowing lake 
water, the life of the organisms ranged from eight to ten days. 

*24th Rpt. Loc. Gov't. Bd. (Sup.), 95- 1894. 

t Jr. Infectious Diseases, I., 641. 1904. 

$Jr. Infectious Diseases, (Supplement No. 2) p. 40. 1906. 



37 



When the typhoid bacillus was exposed directly to the action of 
sewage bacteria its longevity was greatly diminished, three to 
fiye days being the longest time in which the organisms could be 
recovered. They think that the uniformity of their results, con- 
firming the w^ork of the preceding year in the Avaters of Lake 
Michigan and the Chicago drainage canal, warrants the conclu- 
sion that the longevity of the typhoid bacillus in waters is 
materially effected by the germ content of its surroundings. In 
sewage polluted waters it is unable to survive for more than 
three to fiA'e days, the period of time materially longer than that 
w^hich is noted in normally unpolluted waters. 

In 894 samples of water received from various sources 
Busquet* found typhoid bacilli six times. According to 
Bertrand the typhoid bacillus may survive in the sediment in the 
lower part of masses of water for a period as long as three 
years. Samples of water should be investigated not only from 
the surface wells and from their central portions but particularly 
from the bottom of the well. In five of his positive results 
Busquet had obtained the samples of water from the bottom of 
the well in which some of the sediment had been taken with the 
sample. 

Bordonit and his fellow workers have determined that the 
typhoid bacillus retains its vitality two weeks in sea water. 

Fischer and Flataui obtained the typhoid bacillus with all its 
bacteriological characteristics in a sample of water sent to the 
laboratory. This sample came from a well in a village in which 
the inhabitants of two neighboring houses obtained their w^ater 
from the w-ell. Eight persons were sick in these houses wdth 
typhoid fever. In examinations made four weeks later the 
typhoid bacillus could not be detected in this water. 

Mr. Geo. W.. Fuller says that the long continued investiga- 
tions at the Experiment Station of the State Board of Health 
at Lawrence, Mass., show that the typhoid fever bacillus con- 
tinues to live in the waters of the Merrimac river, in greatly 
diminished numbers, for a period of at least twenty-four days. 

*Annal. d'Hyg. Pub.— Deutsche Viert. f. off. Ges., (Sup.), XXXVI., 
169. 1905- 

t Giornale della Real. Soc. Ital. d'Igiene, XXL, 500. 1899. 
t Centr. f. Bak., XXIX., 329. 1901. 



38 



The Question of the Self -Purification of Rivers. — In the con- 
sideration of the dangers from water-borne infection the ques- 
tion of the self-purification of rivers has been considered of so 
great importance that much scientific work has been done to 
elucidate it. 

That rivers and other streams have some power of purifying 
themselves both chemically and bacteriologically is shown by the 
investigations of Professor Nichols* of Boston ; by Frank** in 
examining the waters of the river Spree above and below Berlin ; 
by Prausnitzf for the Isar at Munich; by Uflfelmannt for the 
river Nebel ; by Schlatter§ for the Limmat at Zurich ; by 
Draer§§ on the Pregel above, within the city limits, and below 
Konigsberg ; by Delepine|| of Manchester, England, in his study 
of currents of water artificially conducted through an apparatus 
which he had devised ; by Blasius and Beckurts^^ in the study 
of the waters of the Oker supplying Brunswick, Germany ; by 
Jordan, Russell, and Zeit. in their investigations of the water 
of the Chicago drainage canal, and by others. 

Various agencies are operative in bringing about a partial 
purification of polluted river waters, some of which are: 

Dilution does not destroy bacteria, but simply lessens their 
numbers in a given quantity of water, if the diluting water is 
purer. 

Sedimentation plays a considerable part in purification, dis- 
posing of a part of the bacterial contents of the waters, tempo- 
rarily at least; but some observations indicate that the life of 
the typhoid bacillus is greatly prolonged in the sediment or mud 
at the bottom of bodies of water. 

Light is rapidly destructive of the bacillus of typhoid fever 
under favorable conditions, but in deep waters, waters which are 
not clear, in ice and snow-covered waters and in cloudy weather, 
and in the night, its influence is very slight. 

*Rpt. Mass. State Board of Health, 1875. 
**Zeit. f. Hygiene, HI., 355. 1888. 

t Der Einfluss der Miinchener Kanalisation auf die Isar. Miinchen, 
1890. 

% Deutsche Viert. f. off. Ges., XXII., 382. 1890. 

§ Zeit. f. Hygiene, IX., 56. 1890. 

§§ Zeit. f. Hygiene, XX., 323. 1895. 

HJr. State Medicine, IX., 502. 1901. 

IITI Deutsche Viert. f. off. Ges., XXVII., 337. 1895. 



39 



Some of the conclusions of Buchner"^ based on his observations 
of the morning and the afternoon fluctuation in the number of 
bacteria in sewage polluted streams Blasius claims are erro- 
neous. The afternoon diminution is in his opinion due simply 
to the smaller quantity of sewage received at that time. 

Oxygenation has been classed as one of the factors in purifi- 
cation, but Whipple and ^layert have shown that the vitality of 
the typhoid bacillus is favored by the presence of dissolved 
oxygen in waters; and as is stated on page 133 Klein found 
that the presence of nitrates tended to prolong the Hfe of typhoid 
germs in sewage. 

The antagonistic action of the common water bacteria is inim- 
ical to the life of the typhoid bacillus, and, at the same time, 
rendering its detection difficult. The energy^ of this antago- 
nistic action, says Frost,! depends on the temperature. At rather 
high or ordinary temperatures the action is very pronounced, 
while at the temperature of the ice chest the typhoid germ may 
grow in the by-products of the other germs, which at higher 
temperatures are quickly fatal. As auxiliary to the ordinary 
bacteria is that of the protozoa which Huntemiiller§ considers 
the principal agents in the destruction of typhoid bacilli. 

Temperature exerts an influence. In winter the process of 
self-purification goes on much more slowly than in summer. 
This with the diminished action of light undoubtedly favors 
winter outbreaks of typhoid fever among the users of some 
water supplies. 

Manufacturing zvastes of some kinds inhibit the multiplication 
of bacteria in waters and the organic wastes from other factories 
enormously facilitate their multiplication. 

Even in the light of the results of all the investigations which 
have been made in these directions, the general demand among 
experts for artificial systems for the purification of sewage 
polluted waters by adequate modern methods before their use 
as public suppHes, confirms the opinion of the English Rivers 
Pollution Commission whic]i prompted their report many years 

*Archiv. f. Hygiene, XVII., 179. 1893. 

tjr. of Infectious Diseases, (Supplement No. 2) p. 76. 

$ Jr. of Infectious Diseases, I., 599. 1904. 

§ Hygienisches Centralblatt, I., 255. 1906. 



40 



ago that : It will be safe to infer from the above results, that 
there is no river in the United Kingdom long enough to effect 
the destruction of sewage by oxidation." 

These notes on water-borne typhoid infection may be closed 
with this remark of Springfeld : " From an epidemiological 
point of view it is probable that there is no self-purification of 
streams, but merely a diminution in the amount of Infection by 
dilution and sedimentation. The distance of the intake of the 
water supply from the point of infection is therefore of less 
importance than the demonstration of the causal relation of the 
cases.* 

Typhoid from Milk Supplies. — In the popular estimation 
infected milk, next to infected water, constitutes the most fre- 
quent source from which typhoid fever is contracted. This is 
probably an error, though milk epidemics of typhoid are fre- 
quent. 

A milk borne epidemic of typhoid fever, as the Monthly Bulle- 
tin of the New York State board of health says, has certain 
characteristics. It is generally abrupt in its onset. A fulminant 
outbreak of typhoid fever in a previously healthy locality always 
suggests it, and while any other infected food may have a similar 
effect, and even a public water supply may be infected on the 
instant, an epidemic in which numerous cases come to light 
within a few days may be suspected as of milk origin. Then it 
is widely distributed, as much so as the milk from one source 
usually is, not affecting a whole community as when a public 
water supply is at fault, not limited to a compact neighborhood 
where a local cause is acting. Several members of a family, of 
a susceptible age, are likely to be affected. All or nearly all of 
those affected will be found to have had milk from one vender 
or possibly from a special part of his milk kept separate from 
the rest, and a considerable proportion of the families using the 
same will likewise be affected. With such characteristics of an 
outbreak the suspected milk should be investigated along the 
lines which have been suggested. The acting cause was opera- 
tive two weeks before the outbreak set in, and as in a recent 
case may have ceased to exist ; this ought to be borne in mind.f 

There is no reason to believe that the cow is in any degree 
susceptible to the infection of typhoid fever, or that her milk, 
before it is drawn, ever contains the typhoid bacillus. But milk 
is easily infected or inoculated by the fingers of milkers or other 



* Deutsche Viert. f. off. Ges., XXXVIII., 35- 1906. 

t Wisconsin State Board of Health Bulletin. 



41 



help in dairies who themselves have recently, or sometimes 
remotely, had typhoid fever; it may be in an atypical and 
unrecognized form, or by persons who attend the sick, or by 
dilution with infected water or by milk vessels or utensils which 
have been washed with such water. It may sometimes be 
inoculated by flies which have access, at the same time, to privy 
vaults or other sources of typhoid infection. 

Dr. John S. Fulton,* Secretary of the State board of health 
of Maryland, reports an outbreak of typhoid fever which 
occurred in Elkton in that state in 1900. There were 64 persons 
living in thirty-nine different houses who had the disease, and 
all these persons obtained their milk supply from the same milk- 
man. Three of these patients had previously been sick with 
typhoid fever; one in 1884, another in 1893, and the third in 
1898. 

An outbreak of typhoid fever in Beverly, Mass., referable to an 
infected milk supply was reported by Dr. Morse, medical inspec- 
tor for the State board of health. f 

" A visit was made to A's farm in the town of Ipswich, he 
being the milkman supplying these families. He had six cows 
at his farm, yielding about fifty quarts of milk daily, which he 
distributed to families in Beverly and Salem ; most of his trade, 
however, being in the first-named city. As an auxiliary supply, 
he obtained four cans from B's farm, and one can from Mr. C. 
All of this milk obtained from, these different sources was mixed, 
with the exception of one can, which he supplied to a family 
by the name of D., and which was milk obtained from his own 
cows. Upon questioning him in regard to the presence of 
typhoid fever at his home, it was ascertained that he himself 
had been ill with the disease fifteen years previously ; and that 
at the present time his son, twenty-one years of age, was ill with 
the disease, having gone to bed on September 18. It was a part 
of the son's duty to assist his father in the collecting and 
delivery of the milk, and it was noted that several days preced- 
ing his going to bed he was in a somewhat weakened condition, 
probably from the invasion of the disease. It was further 
ascertained that at Mr. B's farm seven cases of typhoid fever 
were present, the first one coming down with the disease on 
September 11. The six other cases came down on or about the 
20th of the month, which would indicate that the infection of 
the latter was obtained directly from the first patient. 

*Jr. of Hygiene, I., 422. 1901. 

t32nd Report of State Board of Health of Mass., p. 803. 1900. 



42 



The first case at the B. farm was a boy nineteen years of 
age, who assisted his father in milking and supplying the milk 
to Mr. A. ; and it is a significant fact that at the same time a 
relative of his visiting the house and using the same spring 
water was afterward taken ill at his home with the disease, thus 
confirming the supposition that the original infection existed on 
this farm." 

Dr. Eberstaller,* health officer of Gratz, states that, in the dis- 
trict over which he has jurisdiction, typhoid fever is a great 
rarity, so that when cases occur he can afford the luxury of a 
thorough investigation of the etiological points in the cases. On 
June 20 of this year three persons were received into the hos- 
pital with symptoms indicating typhoid fever. One of these 
persons was a jurist, one an educated artisan, and the other an 
assistant in the Medical Institute of the University, people who 
can be trusted to observe and report facts correctly. All these 
persons declared emphatically that the infection in their case 
must be referred to a gathering which they attended on the 4th 
of June. Further than that they could give no information. 
Investigating the circumstances I learned of sixty-six persons 
who were present at this gathering. Among these sixty-six per- 
sons typical typhoid fever occurred in eleven, the diagnosis being 
confirmed by positive \\'idal reaction. Twelve other persons suf- 
fered from loss of appetite, and part of them had headache, 
disturbance of the digestive tract, etc. All these twenty-three 
persons visited a particular hotel or restaurant where they had 
drank milk. So far as could be learned persons who had not 
visited this restaurant or who did not drink milk there remained 
well. Only two persons among the sixty-six who drank milk 
in that place remained well. Further investigation disclosed the 
fact that the milk was brought to this place from a neighboring 
farm and in the farmhouse there were five typhoid fever patients. 

At the Folkestone Congress a paper was read in which a case 
was mentioned of an individual who, for more than two years, 
was employed to milk cows in several different towns and farms 
of Kent. Wherever he went cases of typhoid fever occurred 
among those who drank the milk of the cows which he tended. 
The names and the fullest details were given, and typhoid fever 



* Deutsche Viert. f. off. Ges., XXXVIII., 59- 1906. 



43 



only ceased when the man, having thus injured his own son's 
busiess, was persuaded to give up altogether his occupation of 
tending and milking cows.* 

This man was undoubtedly a " bacillus carrier," as those per- 
sos are now designated who, after a typhoid infection, continue 
to excrete the bacillus for months and sometimes for years after- 
ward. 

In an outbreak of typhoid fever which occurred in the town of 
Adams, investigated by Dr. Morse, f it was found that the 
patients had all obtained milk from one dealer. He obtained 
his milk from two farms in another adjoining town, it being 
brought to the dealer's home in Adams each afternoon and dis- 
tributed by him personally early the next day. On November 5 
he began to feel poorly, but still continued to work until Novem- 
ber II, when, on account of lack of strength, he gave up work 
and remained at home. The family physician made the diag- 
nosis of influenza, but he was sufficiently sick to remain at home 
until December 2, when he again went to work on his milk 
route. But on December 8 he was obliged to give up work for 
the second time. He lost some weight and considerable 
strength. Suspecting typhoid fever. Dr. Morse obtained a 
specimen of blood from him, and a positive Widal reaction was 
obtained in the laboratory of the State Board, indicating that 
his sickness was undoubtedly typhoid fever, and the subsequent 
development of cases among his customers seemed to indicate 
that such was the fact, for he began to be ill November 5 and 
it was not until November 15, ten days later, that any of his 
customers became ill with the disease. 

In an outbreak of typhoid fever in Louisville, Kentucky, it 
was found that most of the cases, forty-four of them, could be 
traced to the milk delivered from one particular farm, which 
itself, together with the milk house and the cow house, were 
unexceptionable. The water used in washing the cans was 
badly polluted. Dr. Bailey, who investigated the outbreak, 
required that the water be boiled before it was used for cleansing 
the cans. The man innocently remarked that he invariably 

* Public Health, XVI., 751. 1904. 

t Thirty-third Annual Report of Mass., p. 559. 1901. 



44 



washed the cans with boiled water, but rinsed them with cold 
water afterwards.* 

Aside from milk itself, there is the possibility of the trans- 
mission of typhoid fever by some of its products. 

Fraenkel and Kister undertook some experimental work for 
the purpose of determining the fate of the typhoid bacillus in 
buttermilk. Their results indicated that small quantities of the 
typhoid bacilli inoculated into buttermilk are not destroyed by 
the acids contained in it within forty-eight hours, a length of 
time which scarcely ever elapses between the period at which the 
buttermilk would be likely to be infected and its consumption. 
The possibility of infection through buttermilk must therefore be 
admitted. 

Heim (cited by Laserf ) published the results of his investiga- 
tions concerning the length of time during which cholera, 
typhoid, and tubercle bacilli may retain their life in milk and 
butter. 

In cheap kinds of rancid butter Heim was able to recover 
colonies of typhoid bacilli three weeks after the bacilli had been 
mixed with the butter. After four wrecks, however, he was 
unable to do so. 

BruckJ says that typhoid bacilli may retain their vitality 
twenty-seven days in butter and that the origin of typhoid fever 
may sometimes be referred to infected butter. 

According to Lydia Rabinowitsch§ the typhoid bacillus 
retains its vitality but a very short time in cheese. 

Typhoid from Oysters. — Among the food products which 
serve as disseminators of typhoid fever, raw oysters undoubtedly 
stand next to milk. The following may be taken as representa- 
tive of outbreaks of typhoid fever due to infectious oysters : 

In 1894 a serious outbreak of typhoid fever occurred at Wes- 
leyan University, and Professor Conn of that institution traced it 
to polluted oysters. Other possible sources of infection could be 
excluded. Nearly all of the victims of typhoid fever were mem- 
bers of three of the seven college fraternities. On October 12, 

* Rpts. and Papers of the Am. Pub. Health Assoc., XIX., 264. 1893- 

fZeit. f. Hygiene, X., 513. 1891. 

$ Deutsche Med. Woch., XXIX., 461. 1903. 

§Centr. f. Bak, (Ref.), XXXIII., 205. 1903. 



45 



eight days before the appearance of the first symptoms, all seven 
of the fraternities had their initiation ceremonies and had cele- 
brated in the usual way with a supper. No other dish except 
oysters were from a common source and could in any way be 
incriminated. Four of the societies had their oysters from a 
local dealer, one of them took their oysters cooked. Of the 
remaining three two had no oysters, and the third had some from 
another source. The oysters from the local dealer which were 
received by the three societies in which the cases of typhoid fever 
occurred, were served on the half shell. 

It was learned that at these same suppers quite a number of 
persons present were not students at the college. Some of these 
were a number of the alumni of the college and five students 
from Yale. Among the alumni there were several cases of 
slight illness which appeared at the same time with the cases of 
typhoid fever at the university, and in addition to these there 
were four cases of genuine typhoid fever among the alumni. 
Of the five Yale students who attended the banquet, two devel- 
oped typhoid fever. It was learned that the oysters came from a 
place near the outlets of a number of private sewers, and that 
in a house from which one of these sewers came there were two 
cases of typhoid fever one of which proved fatal. These two 
cases of typhoid fever occurred at the proper time to be consid- 
ered the source of the infection which the oysters carried. 

Extending the inquiry to other places it was learned that 
seven students at Amherst had typhoid fever. One of these 
students contracted typhoid fever at His own home, and the 
remaining six attended a banquet on the same date as the ban- 
quet at the Wesleyan University, and, at the Amherst banquet, 
raw oysters from the same source as those which caused the 
Wesleyan outbreak were served. One young man from Boston 
who was at Middletown about the date of the banquets came 
down with an extremely severe case of typhoid. 

George A. Soper, Ph. D., a sanitary engineer, of New York, 
presented^ a comprehensive and lucid history of an outbreak of 
typhoid fever at Lawrence, N. Y., due to oysters. The total 
number of cases of typhoid fever of which he had knowledge was 
thirty-one. There were three deaths. None of the cases were 

* Medical News, LXXXVL, 241. 1905. 



46 



due to insanitary conditions, and the water and milk and other 
food suppHes could be excluded in the search for the cause of 
the outbreak. More than two-thirds of the cases were traced 
directly or indirectly to shell-fish taken from water polluted with 
sewage. In the report it is said that at least two hundred times 
as many oysters and clams were shipped away as were eaten in 
the vicinity, and it was thought possible that thousands of cases 
of typhoid fever may have been caused among the people who 
ate those oysters. In the judgment of the reporter pollution of 
Jamaica Bay by sewage was the cause directly or indirectly of 
twenty-one of the thirty-one cases with which the investigation 
was concerned, and that the conditions found there fully war- 
ranted the opinion that, not only have the oysters and clams 
taken from these waters been unsafe to eat, but their shells have 
been dangerous to handle. 

Sears^ reports on typhoid fever in the city hospital from the 
first of January to the middle of November, 1903. There were 
two hundred and three cases which came under his observation 
and they were furnished by two distinct epidemics. The first 
of these outbreaks of typhoid fever fell upon a colored school, 
the pupils of which, during an excursion down the harbor, 
amused themselves by digging and eating clams. 

Sir William Broadbent has found many cases of typhoid fever 
in his practice among the wealthy classes of London, which were 
traceable to the eating of raw oysters. One of the cases he saw 
was that of a young woman in which the sanitary arrangements 
of the house were perfect. The water and milk which she had 
taken had been boiled. No other inmates of the house were sick 
in any way. She had eaten oysters ten days before she came 
down with typhoid fever. 

In another instance he visited two young men living in the 
same house in which there had been no history of any other cases 
of typhoid. The house and the place of business where both of 
these young men were employed were in good sanitary condition. 
They were both attacked at the same time with typhoid fever m 
an unusually severe type for which there was no other cause 
except that ten days before the appearance of any symptoms 



* Boston Med. & Surg. Jr., CXLVIII., 142. 1903. 



47 



they had eaten an oyster supper together. Both cases termina- 
ted fatally. 

A young woman and her cousin had on two occasions eaten a 
half dozen oysters. The young women came down with typhoid 
fever ten and fourteen days respectively, after eating the oys- 
ters, the one in London and the cousin in Italy, whither she had 
journeyed. 

A man and his wife both came down with typhoid fever at the 
•same time in a house which was sanitarily perfect. No possi- 
ble cause was apparent other than the fact that two weeks before 
they had eaten oysters. 

Dr. Broadbent was called into the country where typhoid 
fever was unknown, to see a clergyman and his daughter who 
were both suifering with typhoid fever. Investigations could 
disclose no other cause for the disease save that about two weeks 
before they had twice had oysters from London, and they alone 
had eaten them.* 

Sacquepeef had under his observation in Rennes a number of 
■cases of typhoid fever which were undoubtedly referable to the 
eating of oysters. Particularly noteworthy were the cases of 
four w^omen who together ate a basket of oysters. Three of 
them were attacked with typhoid fever, while the fourth, who a 
w^hile before received a protective inoculation against typhoid 
fever, failed to take the disease. 

Dr. Newsholme,^ Medical Officer of Health of Brighton, 
England, has shown that of the cases of typhoid in Brighton, of 
local origin, in the four years 1893-1897, 33 % of them were 
traceable to shell-fish. 

Whittier§ reported an outbreak of typhoid fever at Marion, a 
summer resort on Cape Cod. 

A house party of six sat down to oysters on a blazer, three of 
the number had typhoid. A plain or even fancy roast is mere 
child's play to a microbe that hibernates in a cake of ice and 
comes up smiling the next summer. 

Blenkinsop's Cove, a mile or more long, on the eastern side of 
the harbor and about a mile across from Marion Village, had 

* British Med. Jr.— Revue d'Hygiene, XVII., 246. 1895. 
t Revue d. Hyg. — Hyg. Rundschau, XIII., 1903. 
I Annual Rpt. for the Borough of Brighton, p. 24. 1897. 
§ Boston Med. & Surg. Jr., CXLIV, 444- iQOi. 



48 



been the chief source of the supply for the summer trade, until in 
midseason the demand increased and emergency calls arose; 
then, for convenience in quick delivery, etc., the clean oysters 
from across the harbor were kept in storage in places polluted by 
filth and contaminated by sewage. The State Board of Health 
reports the bacillus coli communis in oysters taken from various 
places on the village side, none in oysters from Blenkinsop*s 
Cove. 

These instances show the danger from the consumption of oys- 
ters in the raw state which have come from unsuitable places. 
There is nothing in the histories of outbreaks of typhoid fever 
referable to oysters to indicate danger in oysters from clean 
waters. Invariably, when the source from which the oysters 
have come has been learned, they have come from waters which 
have been exposed to sewage pollution. If the oyster industry 
is to escape severe losses, and the lives of people who consume 
oysters are to be duly safeguarded, comprehensive legal provis- 
ions should be forthcoming forbidding absolutely the "fatten- 
ing" of oysters near the outlets of sewers. 

On the experimental side of the question, the following has 
been brought out : 

In the experimental work of Professors Herdman and Boyce''' 
in the artificial feeding and cultivation of oysters and on the 
action of sea-water upon the growth of the bacillus of typhoid 
fever, the following points were developed. In sea-water at a 
temperature of 35 degrees C. the bacillus lives two weeks, and in 
cold water it was found at the end of three weeks. Oysters 
which have been infected with the bacillus clear themselves 
pretty rapidly when subjected to a running stream of pure, 
clean sea-water. There was a great diminution or total disap- 
pearance of the bacillus in from one to seven days. 

Dr. Klein's experiments leave no doubt that the typhoid bacil- 
lus can live for many days in sea-water and sewage, and that, 
when oysters have been laid in such mixtures, the organisms can 
be found within the shells. f 

Prof. Hewlett^ of Kings College, London, refers to the 
experiments of Klein, and then describes his own experiments 



* Public Health, IX., 60. 1897. 

tjr. of State Medicine, V., 73. 1897. 

$Jr. Preventive Medicine, XIII., 779. 1905. 



49 



which also show that oysters from polluted localities rapidly 
clear themselves of Bacillus coli, thus indicating that this bacillus 
is foreign to the oyster and is rapidly destroyed by it. It follows 
from these experiments that both the Bacillus typhosus and the 
Bacillus coli communis are microbes alien to the oyster, and 
when present in it must have been derived from the surround- 
ings. 

Typhoid Fever from Other Food Products. — Probably out- 
breaks are occasionally due to the infection of articles of food, 
other than milk and oysters. Circumstances have sometimes 
thrown suspicion upon vegetables eaten raw, particularly celery 
and lettuce grown upon ground enriched with a fertilizer con- 
taining human excreta, and in England, cress grown in polluted 
water. 

Experimental work was carried on by Clauditz"^' for the pur- 
pose of determining the degree of danger of transmitting typhoid 
fever through the medium of plants and vegetables which are 
consumed in a raw condition. He found no difficulty in demon- 
strating the presence of living typhoid bacilli on the surfaces of 
plants which had been grown in earth contaminated with the 
bacillus of typhoid fever, and he found that simple washing of 
the surfaces of these vegetables did not suffice to remove the 
pathogenic bacteria. 

There are two possible ways in which bread may communicate 
infection. If mixed up with polluted water or other material, or 
the dough infected with unclean hands, the sterilization of the 
interior of the loaf is not absolutely certain, particularly as much 
American bread is underdone. Drs. Waldo and Walshf cultiva- 
ted thirteen different microorganisms from the center of loaves 
of bread soon after they were baked. This danger is slight in 
comparison with that of infection with dirty hands or otherwise 
after the bread is removed from the oven. The conditions of the 
bakeries which the English investigations have disclosed, sug- 
gest that the bakeries in every country should be kept under offi- 
cial sanitary control, — direct communication of the bakeroom 
with water closets, flooding with sewage, which in one instance 
at least was stopped with the rolling-pin, flies swarming the 
bakery which had free access at the same time to sources of filth, 

*Hyg. Rundschau.— Revue d'Hygiene, XXVII., 550. 1905. 
t Lancet, 1894. Vol. II., 906. 

4 



50 



want of ventilation and the bakerooms used as sleeping quarters, 
etc. 

The experiments of Troitski* showed that the bacillus of 
typhoid fever can retain its vitality upon the crust of a loaf of 
white bread or upon the softer middle portion, from 25 to 30 
days or more. Upon rye bread the life of the bacillus was much 
briefer. 

It should be remembered that the danger from an infected 
water supply is not always escaped by using bottled or aerated 
waters, soda water, or beer. These drinks, recently prepared 
from infected water, lose their infectivity only after some time. 

The investigations of the Imperial Board of Health of Ger- 
many, disclosed the fact that the typhoid bacillus may remain 
alive and dangerous for five days.f 

Dr. Eberstaller,J at a meeting of the German Public Health 
Association in 1905, gave the following histories ot an outbreak 
of typhoid fever in which the infection was transmitted through 
the medium of bottled beer : 

The persons affected were mostly of the better class. There 
was a total of twenty-four cases. An investigation disclosed the 
fact that the beer which was incriminated had been bottled by a 
man on the third day of his illness which had necessitated his 
removal to the hospital where he had a run of typhoid fever. 
On the day while engaged in this he was suffering from severe 
diarrhoea. In filling the bottles he made use of a rubber tube 
through which he sucked the beer to start the siphon, and han- 
dled the end with his fingers which were inserted into the 
mouth of tlie bottles to be filled. This investigation led to the 
establishment, under official regulations, of less objectionable 
methods of filling beer bottles. 

Air-Borne Infection. — Indoors, in infected rooms, or in han- 
dling infected clothes dry, infection may occur, but in the open, 
under the conditions in ordinary life, distribution or infection 
through the air is hardly worth considering. But in the report 
on military camps, already quoted, the authors state : 

"It is probable that the infection was disseminated to some 
extent through the air in the form of dust. So prevalent was 
typhoid fever at Chickamauga that much of this fecal matter 



* Revue d. Hygiene, XVI., 726. 1894- 

tArbeiten a. d. Kaiserl. Gesundheitsamts. XL, 15. 1887. 

$ Deutsche Viert. f. off. Ges., XXXVIII., 60. 1906. 



51 



must have contained the Eberth bacillus, and it seems hardly 
possible that the great clouds of dust in which the men lived 
could have been free from this infection. The shell roads 
through the encampments at Jacksonville were ground by the 
heavy army wagons into an impalpable dust several inches thick. 
Along these roads scavengers carted in half barrels fecal matter 
containing the typhoid bacillus. The contents of these tubs fre- 
quently splashed over and fell in this dust. On each side of 
these roads soldiers were encamped, and many mess tables were 
in close proximity to the roads. Local whirlwinds sometimes 
caught up large quantities of this dust and carried it consider- 
able distances. After seeing these things, we feel that we can not 
exclude the dust as a probable carrier of the typhoid infection, 
notwithstanding the fact that it Avould probably be a very differ- 
ent thing to scientifically demonstrate that the disease was dis- 
seminated in this way. 

Tooth"^ assigns four causes for the prevalence of typhoid 
fever while he was in camp on Modder river in South Africa in 
1899: First, the water of the river of which the soldiers could 
not be restrained from drinking; second, infection in the 
dust which was blown about by the winds ; third, flies ; fourth, 
direct infection from person to person. 

Other Sources of Infection. — There are possibilities of infec- 
tion from an infected water supply in the home even when it is 
not used as drinking water. In the report of Reed, Vaughan 
and Shakespeare, already cited, two cases of typhoid fever are 
narrated in persons who did not drink the infected water but 
used it with their toothbrushes ; and b.vo more who gave them- 
selves treatment with the nasal douche, using the infected water 
for this purpose. 

Primary and Secondary Cases. — In outbreaks of typhoid fever 
there is often a great difference in the histor}- of the primary and 
the secondary cases. The earlier cases may have been due to 
an infected water supply or milk supply and have developed 
suddenly, while subsequent cases, due to contact infection, trans- 
mission by flies, or the infecting of home environments, may 
prolong the prevalence of the disease and present an epidemi- 
ologic picture different from that which was seen at first. Thus 
conflicting opinions may be held as to the cause of the disease by 
persons whose observations do not take in the whole field of the 
epidemic as regards time and territory. 



* Lancet, 1901, Vol. I., 79. 



52 



Referring to the study of the epidemiology of typhoid fever 
made by the French school and particularly by Bretonneau, 
Almquist"^' remarks that in their works the unprejudiced reader 
is compelled to acknowledge that cases of typhoid fever imported 
into small places where subsequently the course of the disease 
may easily be studied, show that typhoid fever is a contagious 
disease and is exceedingly dangerous for the neighborhoods. 
As a corrective of certain localistic theories I can heartily recom- 
mend the study of their works, but a detail relating to typhoid 
infection well known to earlier French observers has, it is 
strange to say, disappeared from the text books on typhoid 
fever. 

Almquist here refers to the fact that the period between the 
appearance of the first case of typhoid fever and the next follow- 
ing cases is from three to four weeks. As Gengron says, a few 
of the secondary cases appear within a briefer period of time, 
but they are the exception to the very general rule. He further 
affirms that the incubation period for typhoid fever is seldom 
longer than from eight to ten days and occasionally very short. 

Piedbache who studied typhoid fever in rural hamlets or vil- 
lages, observed 452 cases between the years 1839 and 1848. He 
reports that typhoid fever had extended itself in a very uniform 
wa}'-, to wit: that between the primary and the secondary cases 
from three to four weeks elapsed. He describes in detail many 
house epidemics in which this rule is observed. The secondary 
cases appear most frequently when the primary case was in the 
fourth week. 

Almquist narrates the following in his own experience as 
illustrating this point. A sen^ant girl became sick August 8, 
and was carried to her peasant home August 18. After her 
arrival from the 12th of September on, several of the members 
of her family, her parents and brothers and sisters, became sick 
with typhoid fever. Several persons in the city, who received 
milk from this house, became sick from September 17th on. 
» There was, therefore, a period of about four weeks after her 
return home before new cases of the disease occurred among the 
persons who came in contact with her, although in the small and 
thickly populated house there was no isolation whatever. He 



*Zeit. f. Hygiene, X., 163. 1891. 



53 



refers to other similar personal experiences of his own and of 
his associates. 

Almquist therefore enumerates the following rule : When a 
case of typhoid fever gives rise to secondary cases, these appear, 
as a rule, not until from three to four weeks have passed and 
then it often occurs that several persons who have been exposed 
to the first case come down simultaneously. 

Von Rieder in reporting an epidemic of typhoid fever' in Riga 
in the year 1900, states that this outbreak was caused by an 
infected water supply, but that in connection with the outbreak 
there were a large number of secondary cases in which the infec- 
tion was from person to person. One of the house physicians 
in the hospital and thirty-eight of the nurses attending the cases 
of typhoid fever came down with the disease, and several out- 
breaks in families strongly indicated contact infection. 

Atypical Cases of Typhoid Fever. — To require every case of 
typhoid fever to conform with the text-book picture of typical 
cases would be a practice extremely dangerous to the public 
health. Very atypical cases of typhoid fever, as well as of other 
infectious diseases, frequently occur, and the delay in expressing 
a positive opinion on these difficult cases, is creditable to the 
attending physician, the sanitary precautions required under 
such circumstances being observed meanwhile, for the infection 
is often present early in the stools of mild typhoid and of 
atypical cases. 

Dr. C. E. Woodruff, surgeon U. S. army, says : 

" Investigations by W^idal's test have shown that typhoid infec- 
tion can exist in myriad forms even without intestinal lesions, 
and the atypic forms thus assume a great military importance. 
Every such case introduced into a crowded camp may infect the 
whole army so as to disable it, even though the original patient 
is not bedridden. The serious typhoids with abdominal symp- 
toms are of no military importance, for every one recognizes 
them. The real danger is in the short mild cases in which the 
patients are allowed to run about, spreading the infection broad- 
cast — the cases which local pride or fear of public condemnation 
leads so many physicians to call a ' touch of maleria ' or ' bilious- 
ness ' or any other non-com.mittal diagnosis. Not less danger- 
ous are the atypic cases without abdominal lesions, but having 
the infection confined to the lungs, kidneys, meningies, bones, 



* American Medicine, VIII., 1091. 1904. 



54 



or indeed any other part, for no tissue seems to escape. It is 
believed that these cases costitute a large proportion of all the 
infections. Osier reports the case of an old man who died of 
pneumonia, from whom pure cultures of the typhoid bacillus 
were obtained from the lungs, spleen and other organs, and yet 
there were no intestinal lesions. 

In a paper on mild and abortive forms of typhoid fever Dr. 
Briggs,"-^ of Washington, D. C, says : 

" Probably no one of the common infectious diseases has so 
many points of interest for us, both as citizens and as physicians, 
as has typhoid fever. Alany an epidemic of typhoid fever, 
whose origin is officially traced to a perfectly constructed water- 
supply system, should rather be laid at the door of the medical 
attendant upon the early, often imported, cases, who has been 
satisfied with a purely formal disinfection of stools and urine, 
either taking the most superficial precautions, or recommending 
the use of disinfectants of notorious inefficiency. 

" A diagnosis of ' simple fever,' or of a gastric upset, is 
fatally easy to make, especially as in most instances no imme- 
diate unpleasant consequences will force attention to one's error." 

Reviewing the typhoid fever condition in the Spanish-Ameri- 
can War, Dr. Anderson,t of Washington, D. C, says that " it 
should be a golden rule that every case of continuous fever be 
considered typhoid until proven otherwise." 

Typhoid fever " says Drigalski, assumes varied forms. 
Sometimes it is masked, sometimes it resembles influenza, 
bronchial catarrh, or even pneumonia, or gallstone colic which 
may be caused by the bacillus in the gall bladder. Gastric or 
intestinal catarrh should be considered suspicious, and so should 
various forms of angina. The typhoid bacillus may be present in 
persons who present a complete picture of health. Particularly 
in children typhoid fever assumes an atypical form." 

Bezancon and Philibert state that the typhoid bacillus may 
produce a general blood infection without local intestinal lesions. 
They narrate fifteen cases of this form of typhoid intoxication. 
These cases were distinguished by the absence of abdominal 
symptoms, of the characteristic eruption, and of marked enlarge- 
ment of the spleen. In the severe forms of Eberth's infection 
the presence of the typhoid bacillus is constantly present in the 
general circulation. This form of the disease can be considered 

* American Med. VIII., 644. 1904. 
t American Medicine, III, 476. 1902. 



00 

as a general infection with or without secondary localizations 
in the intestinal tract. 

In a second memoir on this subject in the same journal, the 
authors repeat that the typhoid bacillus may not only produce 
the specific blood poisoning without the appearance of localized 
lesions, but the infection may localize itself upon almost any 
organ of the body, with or without a tendency to general infec- 
tion. Seventeen observations were made in which meningitis, 
lobular pneum.onia, inflammation of the gall bladder, of the 
kidneys, the joints, and of the glands, were referable to the 
typhoid bacillus. The enlargement of the spleen may constitute 
the only typhoid symptom. 

In these cases the diagnosis can be made only with the help 
of the Laboratory — diazo-reaction, sero-diagnosis, cultures from 
the blood and feces. There is some difficulty in making a diag- 
nosis between these forms of typhoid fever and paratyphoid 
fever.* 

In a paper read before the Xew York State ^vledical Associa- 
tion Dr. Louis C. Jaeger of Xew York, took up the subject of 
typhoid fever in children. He said that by no means all the 
members of the medical profession had yet divested their minds 
of the old fallacy that typhoid is a very rare condition in young 
children. In a summary of his paper the doctor says that 
typhoid fever in children is almost invariably of brief duration 
and that the temperature, as a rule, is not excessive. 

On the other hand, Dr. Morsef of Boston, in a paper on 
"Infantile Typhoid Fever" expresses the opinion: "In the 
light of our present knowledge, the symptomology of typhoid 
in infancy is essentially the same as in adult life, and it is really 
and not apparently infrequent at this age." 

WeichardtJ describes a case of typhoid fever in the course of 
which the predominating symptoms were referable to the central 
nervous system while those which are considered pathognomonic 
for typhoid fever were wanting. The autopsy gave no distinct 
points for the diagnosis of typhoid. The bacteriological investi- 
gation, however, gave the typhoid bacillus with all its specific 

*Journ. de Physiol.— Centr. fiir Bak. (Ref.) XXXVII., 233. 1905. 
t Medical News, LXXXIIL, 193. 1903. 
tZeit. f. Hygiene, XXXVL, 440. 1901. 



56 



characteristics. Weichart considers such cases as this in which 
the diagnosis of typhoid cannot be made, and in which the 
necessary precautionary measures, including the disinfection, are 
disregarded, as extremely dangerous from the point of view of 
the public health. 

A'elich''' reports on thirty-six sudden deaths in which at the 
autopsy typhoid fever was found to exist. In twenty-five of the 
cases, in addition to the typhoid fever, disease of the heart was 
present, and in all the remaining cases there was other severe 
disease present. During the illness typhoid fever was not sus- 
pected and was first recognized at the autopsy. These cases of 
latent typhoid fever have great significance from the pubHc 
health point of view. 

In a discussion before the Xew York State Medical Associa- 
tion in 1905,1 on the frequency of types of abrupt typhoid fever^ 
Dr. j\Ianges said that this form of t}'phoid fever, abrupt onset, 
is much more common than has been supposed, and as it is likely 
to be severe and needs treatment early it is necessary the diag- 
nosis should be made at the earliest possible moment. In Dr. 
Manges's experience and according to the records of the Mt. 
Sinai Hospital, about ten per cent, of all typhoid cases begin 
abruptly. The causes of the sudden onset of symptoms in these 
cases seem to be the silent progress of the bacilli until all resist- 
ance is overcome when the organism gives wav. There are two 
forms : the first is the genuine abrupt typhoid fever, and the 
second, the apparently abrupt. These latter are walking typhoid 
cases. Some of the cases resemble paratyphoid and in these the 
Widal reaction is the best possible diagnostic sign; in other 
cases the headache is so severe as to simulate meningitis. In 
some cases the temperature is extremely high. Sharp, hard 
chills occur in about two per cent, of the cases. 

Dr. Stockton, of Buffalo, said, whenever typhoid fever selects 
a special organ for its attack, then the symptoms of its presence 
are almost sure to announce themselves suddenly. Dr. Mori- 
arity, of Saratoga, referred to groups of cases of typhoid fever 
occurring in the hospital ; four nurses, two orderlies, and three 
patients. None of them had prodromal symptoms. In two of 



*Arch. f. Hygiene, XLIX., 113. 1904. 
t Medical News, LXXXVIL, 380. 1905. 



57 



the cases there was so much abdominal pain that they were 
thought to be cases of appendicitis. One of them was decidedly 
hem.orrhagic in character and ran a severe course. All of them 
had slow pulses. 

In the report of Reed, Vaughan and Shakespeare, several r 
times quoted in these notes, it is affirmed : " It is altogether pos- 
sible for an individual to carry in his alimentary canal and elim- 
inate therefrom the Eberth bacillus in virulent form without 
having the disease himself. The probabilities are that the 
majority of men who reach 40 years of age have at some time 
or another carried this germ in their bodies, and this may 
account for the fact that men of this age are less susceptible to 
the disease than younger men." 

Jurgens"^ of Berlin holds that the presence of the typhoid 
bacilli is far from being synonymous with the disease. Follow- 
ing Koch's example, all the infected persons in an infected 
family were examined for typhoid bacilli, regardless of whether 
they were sick or well. This revealed a number of slight, 
atypical cases of typhoid, and also disclosed the presence of the 
bacilli in certain absolutely healthy subjects. The bacilli in the 
milder cases were sometimes far more virulent than in the severe 
ones. The resistance of the individual is evidently the deter- 
mining factor. The disease process is identical for all, but 
dif¥ers in its degree. 

Conradif relates that in the discharges from the bowels of a 
child sick with typhoid fever, in addition to numerous typhoid 
bacilli, a number of paratyphoid bacteria were found (on 
Drigalski-Conradi plates). The infection was supposed to have 
been received in ice which the child consumed. Symptoms of 
the fever appeared eight days later. In the Municipal Hospital 
occasionally an epidemic of typhoid fever occurs referred to 
contact infection. In the discharges of some of the sick, typhoid 
bacilli may be found, while in those from other patients the 
paratyphoid bacilli are present. A physician who was not sick 
discharged by stool both typhoid and paratyphoid bacilli, while, 
at the same time, his serum possessed no power of agglutination. 
The bacteriological investigation was made twice within eight 
days. 



* Public Health, XVI., 751. 1904. 
tCentr. f. Bak. (Ref.) XXXV., 764. IQOS- 



58 



Two years ago, says Fischer,* we had an outbreak of typhoid 
in Kiel in which there were eighty cases, and, after a careful 
investigation of the circumstances, we were forced to conclude 
that the disease was due to the eating of the meat of a sick 
animal. This experience is not unique. Three years previously 
we had a similar experience. In a small place near Kiel fifteen 
persons suddenly were attacked with typhoid fever, and the per- 
sons exclusively were attacked who had eaten the meat from a 
sick calf. Similar epidemiologic observations have come from 
the province of Plon. In the Kloten epidemic also 600 of the 
visitors to a music festival became sick after partaking of meat 
which had been derived from a sick animal. In the epidemic at 
Kiel of which I have spoken, in which the disease presented the 
appearance of typhoid, the paratyphoid bacillus was found 
instead of the true typhoid bacillus. 

I may add that last year we had an epidemic in a small city 
in which there were sixty cases which presented generally the 
typical clinical picture of typhoid fever, yet we were unable to 
find either the specific typhoid bacillus or the paratyphoid 
bacillus in the dejections or in the blood. This and some similar 
experience force us to the conclusion that, aside from typhoid 
bacilli and the two hitherto described paratyphoid germs, there 
must be other unknown bacilli which sometimes cause a disease 
identical with typhoid fever or closely resembling it. 



* Deutsche Viert. f. off. Ges., XXXVIII., 57. 1906. 



NOTES OX DY5EXTERY AXD CHOLERA. 
By the Secretary of the Board. 

These few notes are presented for the purpose of bringing 
out the parallelism which exists between these two diseases and 
typhoid fever, so far as the methods in which their distribution 
is concerned. These three diseases are the chief components 
of a group which have been known as water-borne. While the 
rapid spread of typhoid fever and cholera through the medium 
of infected water supplies has constituted the most dramatic 
phase of their epidemiology, we need to grasp clearly the teach- 
ings of the obser\'ations of recent years, that these diseases are 
largely spread irrespective of water as a medium of transmis- 
sion, and often in fact when the influence of water supplies can 
entirely be eliminated — spread directly from person to person, 
by " contact infection,'"' favored usually by the unclean environ- 
ments of the people. 

Xofes on Dysentery. — In a report on an outbreak of dysentery 
in the Connecticut Hospital for the Insane in 1903, Drs. Diefen- 
dorf and Fisher^ state that the origin of the epidemic could not 
be traced to sources outside the hospital, including the food, 
water, and milk supply. A considerable majority of the cases 
they think resulted directly or indirectly from contact with infec- 
tive material in the hospital — dejecta of patients. The bacillus 
dysenteric was recovered in one-third of the cases studied. 

Following the Franco-German war of 1870 and 71, says 
Rottger.i there was a marked increase in the prevalence of 
dysentery. The susceptibility to dysentery is about the same at 
all periods, but the mortality rate is much greater in the earlier 
years and again at the advanced period of life. 

An outbreak of dysenter}^ occurred in Bremen in July, 1899. 
A careful investigation showed that, as early as the end of June 



*26th An. Rept State Board of Health of Conn., p. 234. 1903. 

t Centr. f. allg. Ges.— Deutsche Viert. f. off. Ges., XXXIIL, 167. 1902. 



6o 



in some houses on the streets in which the outbreak occurred,, 
there had been cases of intestinal disease which were probably 
dysentery. In what way the infection was first introduced has 
not been explained, but the disease spread slowly, first in the 
families of the sick, until the beginning of September, when 
there w^as a rapid increase in the prevalence of the disease. The 
outbreak reached its maximum in the third week of that month 
with 130 cases. There was a total of 591 cases with 66 deaths. 
It was observed that the disease gradually spread from house to 
house and from street to street. The infection of the drinking 
water could, therefore, apparently be excluded, and the way in 
which the disease spread indicated contact infection or the 
extension of the infection from person to person as the result of 
injudicious association with the sick, and contact with soiled 
body and bed clothing of the sick, the infection of food with the 
hands of the sick or of the attendants upon the sick, etc. The 
social and sanitary conditions of the people in this part of the 
city were far from satisfactory. 

An epidemic of dysentery which appeared in one of the 
German army barracks was investigated by Robert Koch"^ and 
he could not find any reason to suspect that the infection had 
come through infected water supply, food, drink, or arrange- - 
ments for the disposal of excreta. Koch came to the conclu- 
sion with the military surgeons that the barracks themselves 
were thoroughly infected. They were therefore vacated. 

Borntraegerf reports on a widely distributed outbreak of 
epidemic dysentery which occurred in the region around Danzig, 
Germany, in the years 1895 and 1896, and furthermore gives 
much inforniation in regard to the prevalence of the same dis- 
ease in the same country in former years. 

In one group of cases there was a total of 1,176 cases of the 
disease with 176 deaths, Avhich was equal to 15 per cent, of them. 
His observations indicated that the average period of incubation 
of the disease was three days, ranging from two to six days. 
He gives many instances which indicate the correctness of his 
conclusions on this point. He is convinced that, as a rule, the 



*Zeit. f. Med.— Deutsche Viert. f. of!. Ges., XXXIV., 163. 1903. 
tZeit. f. Hygiene, XXVIL, 378. 1898. 



6i 



infection of the disease is received by the way of the mouth; 
possibly occasionally by the way of the rectum. The infectivity 
-of the specific organism of dysentery is very great, eiiher that or 
the immunity of man against it is slight, for he had observed 
repeated instances in which all the members of a family of from 
five to eight persons were attacked, one after another, after a 
person sick with that disease had come to that house. The 
endemic history of the outbreak teaches him that the micro- 
organism must have a long period of vitality. Instances are 
cited in which it would appear that the infection must have 
retained its vitality from one to two or three years. 

As to the method in which the disease is communicated he is 
convinced that it is largely spread by direct infection — by con- 
tact with infectious persons and with things which have been 
infected by the patient. The following are a very few of the 
many instances mentioned by him in support of his views : 

A boy returned to his father's house sick with the disease. 
The result was the infection of his own family and later of other 
families in the neighborhood with whom they associated. 
Twenty cases resulted. A man brought the disease from Russia 
to one of the frontier towns of Germany. Forty-eight cases 
resulted. A girl was present at the burial of her brother who 
had died of dysentery. Returning to her home she came down 
with the disease. A young woman was present at the funeral 
of a relative. Returning she brought the disease to the town 
in which she lived and from this implantation of the disease 
sixty-two cases occurred with sixteen deaths. 

A servant girl was brought to her brother's home in H. and 
infected his family, from which the disease was transported to 
three other houses m the neighborhood. Thirteen cases fol- 
lowed this implantation of the infection. Many other instances 
are given in which the disease was transported by persons who 
returned to their homes, and of persons who were infected by 
visiting the sick, or by being present at the burial of the deceased. 

As regards the transmission of the infection through the water 
-supply he makes these statements : the rapidity of the trans- 
mission is against the assumption of water-borne infection, for 
in numerous instances the persons became sick with the . disease 
in from two to three days after their first exposure. This is 



62 



too rapid a transmission of infection to believe that reaching the 
ground it found its way to the water supply and thence to the 
patient. 

Again the fact that the persons who were in the closest asso- 
ciation with the sick ones were the persons who first came down 
with the disease. Other persons in the same house and persons 
in the neighborhood came down gradually one after another. 
The general method was not an explosive outbreak infecting 
many persons at the same time in a group of houses which used 
the same local water supply. 

In the cities when the disease appeared in a family living sev- 
eral stories above the ground and spread from person to person,, 
the influence of the ground as a factor in the local outbreak could 
with considerable confidence be excluded. Against the idea of 
the influence of the ground or the water supply in the propaga- 
tion of the disease he refers to the fact that some of the regi- 
ments infected in the barracks were moved to other quarters in 
the open field. Nevertheless the infection clung to them and 
still further affected them after they had removed to other 
barracks. 

Referring to the usual manner in which infection is spread, 
he reminds us of the conditions of the patient who has this dis- 
ease with some twenty to sixty evacuations in 24 hours. Under 
the circumstances it is altogether impossible for the patient, 
even if of cleanly habits, to avoid the infection of his clothing, 
of his bedding, and of his hands, and eventually everything 
touched by him ; clothing, eating utensils, and manv other things 
in his vicinity are infected. The hands of the attendants, as can 
easily be understood, soon become infected, and there is great 
danger of the transmission by them of the infection indirectly 
to the lips or mouths through the medium of their food and 
otherwise. He observes that this sort of finger infection is 
exceedingly common not only in this disease but in cholera and 
in typhoid fever. 

If this method of propagating the disease can occur in cleanly 
persons it may be imagined how much more favorable for this 
method of transmission it is among the uneducated and uncleanly 
persons in this class of people in the country. 

Infection, in dysentery, occurs in the great majority of cases 
by the mechanical transmission of traces of fecal matter; that 



63 



in fact it has a direct fecal infection, and that the ground cannot 
be considered an etiological factor. Infection is transmissible 
directly from person to person. Practically considered, the 
presence of a person sick with this disease is as dangerous for 
his associates as would be the presence of a person sick with 
sm.allpox. The disease is transmissible in the same way as is 
the infection of cholera. 

Accepting his theory, the explanation of some of the epidem- 
iological histories of dysentery is made clear. It shows why 
the disease is more prevalent in the lower classes of the people. 
It explains in part at least why children are more frequently 
attacked than adults. They are less careful and less cleanly in 
their habits ; they are handling everything, they stick their 
fingers and many other things in their mouth, and out-of-doors 
come m.ore intimately in contact with sources of filth which may 
contain infection. 

As in cholera the effects of the sick, and particularly of the 
body and the bed clothing are infectious. This is indicated by 
the history of a woman who became sick in Danzig after wash- 
ing infected clothing, and by the case of a young woman in 
Krangen who became sick after using the clothing which had 
belonged to persons sick with this disease several years before. 

Repeatedly Borntraeger found articles of food as probable 
carriers of infection in Danzig. Several families were supposed 
to have beeen infected through milk, cheese, fruit, or vegetables 
which had been infected. He admits the possibility of the trans- 
mission of this disease through water supplies, but in these 
outbreaks which he investigated he finds no logical indication 
that the disease was thus spread. 

The control of epidemics of dysentery should be through iso- 
lation of the sick, care for extreme cleanliness of the patient 
and of the surroundings, and particularly of the patient's hands, 
the prompt disinfection and proper disposal of the excreta of 
the patients, the disinfection of all dishes and utensils used in 
the sick room, of the clothing and bedding, and of privies. 
Other persons in the same house must take precautionary^ meas- 
ures observing utmost cleanliness, and particularly should they 
• carefully cleanse and disinfect the hands after they have come 
in contact with the patient and with articles in the sickroom. 



64 



Notes on Cholera. — India has been considered the perennial 
home of cholera. The climate and the life conditions of the 
natives of that country favor the transmission of the disease 
from person to person and favor the continuance of the vitality 
of the infection in the outer world — in the soil and the earth. 
What some of the conditions are were described by Dr. W. J. 
Simpson, in 1894, then Health Officer of Calcutta. 

" The tanks or ponds form a special feature in the physical 
topography of Calcutta. Originally excavated to raise the 
surrounding land in order that huts and houses might be built 
on the raised land, the tanks became useful, first, as reservoirs 
of rain-water for supplying the neighborhood, or the surround- 
ing cluster of huts, with water for drinking and for domestic 
purposes; and, secondly, as a convenient receptacle into which 
the drainage of the locality should flow. Different districts 
differ in the number of ponds which they contain; some are 
honeycombed with these tanks, and during the rainy season 
there is actually in some areas more water than land; others 
have fewer tanks, and a number of them are protected from 
drainage pollution. The public tanks are also, as a general 
rule, well looked after; but the majority of tanks are the mere 
drainage cesspools of the locality. Much has been said regard- 
ing the filthiness of these ponds. They more or less resemble 
pea-soup in colour, and their composition has been officially 
reported as concentrated London sewage. The drainage from 
latrines often find an easy and convenient outlet into their 
waters ; soiled clothes of the sick and of the healthy are washed 
therein ; men, women and children bathe and perform their 
ablutions in the pond, while oxen, buffaloes, horses, goats and 
other animals are taken down to the water's edge, and there, 
given a bath. In such water the inhabitants cleanse their 
domestic utensils and soak, macerate and wash their rice and 
dhal, and not infrequently prepare other kinds of food." 

The spread of cholera from person to person requires the 
transference to the intestinal tract of new victims of some of the 
infection generated in the intestinal canals of the cholera sick. 
As in typhoid fever the transference may take place in various 
ways. 



65 



The large epidemics of cholera have been water-borne, though 
other factors have contributed their share to the distribution. 
Following the routes of traffic, cholera has several times spread 
from our Atlantic and Gulf ports, to which shipping has brought 
it, and prevailed disastrously at interior points, particularly in 
the valleys of the Mississippi and Ohio. Of late outbreaks, that 
of Hamburg, Germany, in 1892, illustrates the rapidity of the 
extension of water-borne epidemics of cholera. The water of 
the river Elbe, from which the city water supply was then taken 
unfiltered, in some way became infected with the bacillus of 
cholera. Within 18 days of the beginning of the outbreak the 
disease had spread rapidly over all parts of the city, and 10,000 
cases had occurred with more than 4,300 deaths. 

The outbreak of cholera in a hospital for the insane in 
Nietleben, Germany, in the beginning of 1893, is an example 
of the winter prevalence of cholera which is not by any means 
unique. The first case occurred in the middle of January. The 
next day there were six new cases, and the third day, eleven. 
There were one hundred and four cases in all, among them three 
physicians and ten nurses and women attendants. It was after- 
ward learned that a man came from Hamburg, where cholera 
had prevailed, and after his arrival suffered from diarrhea, 
which later lead the investigators to believe was cholera in a mild 
form. 

Cholera is propagated by infected water, not only by drinking 
it, but, as in typhoid fever, the presence of infected water in the 
household constitutes a grave danger, for it may find its way into 
the stomach through the infection of dishes, tooth brushes, the 
hands, or lips in washing, etc. 

In the ground the bacillus of cholera may retain its vitality 
some weeks at least under favoring conditions ; and in water its 
life may be considerably prolonged. In one of the water tanks 
of India, investigated by Koch, the cholera bacillus was found 
for fifteen days. Out of fort3^-six water tanks around which 
cholera existed, near Calcutta, Simpson found the cholera 
bacillus in forty-two, that is, in 91 .3%. Under the observations 
of Babes, the cholera germ remained alive in the water of the 
Seine seven days, and the same length of time in the water from 
the public supply of Berlin. According to Nicati and Rietsch, 



5 



66 



it remained viable eighty-one days in the water of the harbor, 
sixty-four days in sea water, and thirty-eight days in canal 
water. 

It has been shown that in or on some food supplies the micro- 
organism of cholera retains its vitality for some length of time, 
or even undergoes rapid multiplication. In his experiments on 
its behavior in milk, Kitasato found that, at the temperature of 
36° C, the cholera bacillus developed very rapidly during the 
first twenty-four hours. They then diminished in numbers from 
hour to hour as the acidity of the milk increased. Aboard a ship 
in the harbor of Calcutta, nine cases of cholera suddenly 
appeared. An investigation showed that these nine persons and 
one other person, had received milk from a native milkman. 
The one person who was spared had taken but very little milk. 
Eight other persons aboard the ship who used condensed milk, 
and three who used no milk at all, remained free from the 
disease. 

Uffelmann has shown that the bacillus, on the surface of rye 
bread open to the air, remained alive twenty-four hours, but 
Avhen the bread is' wrapped in paper it continued viable for three 
days. On roasted meat placed in a bell jar, it was active at the 
end of a week. It -develops luxuriantly in bouillon, on potato, 
and, according to Babes, on fresh meat, cooked eggs, cabbage, 
moistened bread, and legumes. \^arious foods, therefore, not 
freshly cooked, vvhich have been exposed to infection in various 
vays, may transmit dangerous doses of cholera infection. 

The clothing of cholera patients, second hand clothes, scraps 
and rags especially, are to be regarded as particularly dangerous 
and a fruitful source of distribution of infection in cholera times. 
Upon dampened clothing and other fabrics, the bacillus will not 
only retain its vitality, but will sometimes increase luxuriantly. 
Washerwomen have been notoriously exposed to cholera infec- 
tion. This was noted in A^ienna in 1866. In a laundry in that 
cit}', sixteen of the women working there were attacked with 
cholera. In 1873, in the same establishment, there occurred first 
one case, then two other cases, at a time when there were only a 
few isolated cases of cholera in the city. It was shown, how- 
ever, that cholera infected clothing had been sent to this laundry. 
Later, in the same year, another local outbreak of cholera 
occurred in this same laundry. 



67 



Attendance upon the cholera sick under suitable precaution 
is not considered especially dangerous. Some of the character- 
istics of the specific infection of this disease would appear to 
lessen the danger of contact infection, and perhaps lower the 
degree of this danger below that of typhoid fever. While the 
typhoid bacillus is noted for possessing a degree of resistance 
against adverse conditions exceeding that of many pathogenic 
bacteria, the bacillus of cholera is noted for its slight power of 
resistance against adverse conditions. It resists well low tem- 
peratures, but is easily destroyed by low degrees of heat, easily 
destroyed with disinfectants, quickly loses its life upon drying, 
but when subjected to drying under certain conditions in which 
desiccation is not perfect, it may retain its vitality some time; 
according to Uf¥elmann, on the printed page, seventeen hours, 
on writing paper in an envelope twenty-four hours, on textile 
fabrics in a dry state, four days, but when moist, twelve days. 

The investigations made by the Imperial Board of Health, of 
Germany, showed that the disease may be transmitted by 
uncleanly hands, utensils, etc. The fatal case of cholera which 
occurred in the laboratory in Hamburg, in 1894, emphasizes the 
danger of contact infection. 

Most of the experimental work relating to the cholera bacillus 
would lead us to the conclusion that there is little danger from 
air-borne infection, although this danger undoubtedly exists in 
uncleanly rooms where cases of cholera have occurred. The 
transmission of the disease through the air to any great distance 
appears to be entirely impossible. The cholera bacilli dried 
under certain conditions, for instance, with cla}^, sand, or sweep- 
ings, may be dispersed in the dust in a living condition, accord- 
ing to Liebermeister. .There is good reason to believe that the 
infection may be carried by flies. 

As with typhoid fever atypical cases, even so mild that they 
can be recognized only by the help of the laboratory, play an 
important part in the distribution of infection. The " Bacillen- 
trager," that is, persons who have been exposed to the disease 
and have had but mild symptoms, or none at all, may for some 
time continue to be sources of danger to persons and to places 
by discharging cholera bacilli in their excretions. 



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